Health inspection·December 6, 2021

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of his individuality for one (1) of 8 sampled residents (Resident 46). The facility staff was observed sitting on a chair outside Resident 46's room and not attending to Resident 46's call for help in timely manner. This deficient practice had the potential to affect Resident 46's self-esteem and self-worth, due to unmet or unaddressed needs. Findings: During a review of Resident 46's admission Record, the admission record indicated Resident 46 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of, but not limited to, dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning), heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), abnormal posture and unspecified protein-calorie malnutrition (lack of sufficinet nutrition for the body to meet energy demands). During a review of Resident 46's Minimum Data Set (MDS - a standardized assessment and screening tool) dated April 16, 2018, MDS indicated the resident had severely impaired cognitive skills for daily decision-making. The MDS indicated Resident 46 needed total assistance with bed mobility, transfers and dressing, eating, toilet use, personal hygiene, and bathing. During concurrent observation and interview on November 30, 2021 at 3:15 p.m. Resident 46 was heard saying help me, help me, help me and raising his left hand. Resident 46 was lying in bed awake, alert and oriented to name with slurred speech. Resident 46's call light was out of reach as it was laying in the floor on the left side of the bed. Certified Nursing Assistant (CNA) 1 was sitting on a chair outside Resident 46's room. CNA 1 stated that Resident 46's always says help, help, help when he hears voices, but does not need anything. CNA 1 stated that Resident 46 does not know how to use call light. During the same observation Resident 46 was pressing the button of the call light to summon help. CNA 1 acknowledged it was important to tend to Resident 46's needs when he called for help because Resdient 46 is a fall risk, and he might fall trying to get out of bed to help himself , he may fall . During a review of facility's policy and procedure titled Resident Dignity and Personal Privacy release dated 2016, indicated that the facility provides care for residents in a manner that respects and enhance each resident's dignity, individuality, and right to personal privacy. Each resident has Page 1 of 32 555112 555112 12/06/2021 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0550 Level of Harm - Minimal harm or potential for actual harm the right to be treated with dignity and respect. All activities and interactions with residents by any staff, temporary staff or volunteers must focus on assisting the residents in maintaining and enhancing his or her self-esteem and self- worth and incorporating the resident's goals, preferences, and choices. When providing care and services, staff must respect each resident's individuality, as well as honor and value their input. Residents Affected - Few 555112 Page 2 of 32 555112 12/06/2021 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

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 nursing staff member failed to provide reasonable accommodation to meet the resident's needs by failing to ensure the resident's call light was within reach for one (1) out of 8 sampled residents (Resident 46). Residents Affected - Few This deficient practice had the potential to negatively impact Resident 46's psychosocial well-being or result in delayed provision of services. Findings: During a review of Resident 46's admission Record, the admission record indicated Resident 46 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of, but not limited to, dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning), heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), abnormal posture and unspecified protein-calorie malnutrition (lack of sufficinet nutrition for the body to meet energy demands). During a review of Resident 46's Minimum Data Set (MDS - a standardized assessment and screening tool) dated April 16, 2018, MDS indicated the resident had severely impaired cognitive skills for daily decision-making. The MDS indicated Resident 46 needed total assistance with bed mobility, transfers and dressing, eating, toilet use, personal hygiene, and bathing. During concurrent observation and interview on November 30, 2021 at 3:15 p.m. Resident 46 was heard saying help me, help me, help me and raising his left hand. Resident 46 was lying in bed awake, alert and oriented to name with slurred speech. Resident 46's call light was out of reach as it was laying in the floor on the left side of the bed. Certified Nursing Assistant (CNA) 1 was sitting on a chair outside Resident 46's room. CNA 1 stated that Resident 46's always says help, help, help when he hears voices, but does not need anything. CNA 1 stated that Resident 46 does not know how to use call light. During the same observation Resident 46 was pressing the button of the call light to summon help. CNA 1 acknowledged it was important to tend to Resident 46's needs when he called for help because Resdient 46 is a fall risk, and he might fall trying to get out of bed to help himself , he may fall. During a review of facility's policy and procedure titled Answering Call Lights, indicated that the purpose of this procedure is to respond to the resident's requests and needs. Steps are taken to ensure that a resident's need and request is consider when request are made and when call light are used to respond to needs at the time of use. Ensure the call light is plugged at all times. When resident is in bed and confined to a chair, the call light will be placed within easy reach of the resident. 555112 Page 3 of 32 555112 12/06/2021 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0580 Level of Harm - Minimal harm or potential for actual harm Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on observation and interview the facility failed to ensure one of seven resident's (Resident 10) physician was notified in a timely manner when Resident 10: exhibited a change in condition on 7/7/2021. Residents Affected - Few This deficient practice resulted in Resident 10's physician being unaware of Resident 10's change in condition (COC) and delaying care and proper management of the COC. Findings: According to the admission record, the facility admitted Resident 10 on 5/24/2021, with diagnoses that included anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear strong enough to interfere with one's daily activities), hyperlipidemia (condition in which there are high levels of fat particles (lipids) in the blood), and hypertensive chronic kidney disease (high blood pressure caused by the narrowing of your arteries that carry blood to your kidneys). A review of Resident 10's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 09/29/2021, indicated Resident 10 had clear speech and was able to understand others and was able to be understood. Resident 10 required extensive one-person physical assistance with bed mobility, transfer, getting dressed, toilet use, personal hygiene, and extensive assistance with bathing During a concurrent interview and record review with social services designee (SSD) on 12/1/2021 at 9:56 a.m., SSD stated that Resident 10 goes out on pass (leave the facility per agreement and physician's order) and arranged all his appointments as well as transportation. SSD stated when Resident 10 came back from out on pass, facility staff noticed that Resident 10 looked intoxicated with alcohol or drugs not sure which. SSD stated that policy for Resident Drug and alcohol abuse was discussed and signed by Resident 10 back in July 2021 During a review of nursing notes dated 7/7/2021 indicated staff observed changes or abnormal behavior related to non-compliance with facility policy regarding drug and alcohol abuse. During a concurrent interview and record review on 12/2/2021 at 10:45 a.m. with Registered Nurse 1, RN1 acknowledged that there was no notification of Resident 10's Medical Doctor of the Situation, Background, Appearance and Review (SBAR- internal document for change of condition) on 7/7/2021 when Resident 10 appeared intoxicated. RN 1 stated it was important to let the physician know of any changes in Resident 10's status so the physician can order interventions as needed. RN 1 added to the symptoms of alcohol intoxication included changes in body movement, speech, behavior and change of cognition. During a record review of Policy and Procedure (P/P) titled Change of Condition dated August 2017 indicated that the facility shall promptly notify the resident, his or her attending Physician of changes in the resident's medical/mental condition and or status. 555112 Page 4 of 32 555112 12/06/2021 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 licensed nursing staff failed to implement a person-centered care plan for Resident 36. This deficient practice had the potential to result in a delay in delivery of care and services Findings: A review of Resident 36's Face sheet indicated the resident was admitted to the facility on [DATE], with diagnoses that included diabetes mellitus (an impairment in the way the body regulates and uses sugar [glucose] as a fuel), history of falling, chronic pulmonary edema (pulmonary edema is usually caused by a heart condition), unsteadiness on feet. A review of Resident 36's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 11/22/2021, indicated that Resident 36 was cognitively (ability to make decisions of daily living) intact and could make self-understood and had the ability to understand others and required extensive assistance with transfer, getting dressed, toilet use, and personal hygiene. During a concurrent observation and interview on 11/30/2021 at 3:32 p.m., Resident 36 stated that facility staff did not answer the call lights in a timely manner, as a result, Resident 26 stated he had multiple falls trying to reach the urinal by himself. A review of Situation, Background, Appearance, Review and Notify (SBAR- internal document for change of condition documentation) and care plan dated: 1. 10/13/2021 at 12:50p.m. indicated Resident 36 fell. According to the SBAR, Resident 36 was found on the floor inside his restroom and was transferred to the Emergency Room, interventions indicated to assess resident after the fall, keep call light within reach, ongoing verbal cueing for safety, neuro check (an assessment of the nervous system {the way various body parts communicate with each other] as indicated, anticipate, and attend to needs promptly, refer to rehab for evaluation and screening, Continue to educate/remind resident to use call light and wait for assistance. 2. 10/18/2021 at 12 p.m., SBAR indicated Resident 36 was noted on his right knee on floor mat. Care plan interventions included to assess resident after the fall, keep call light within reach, ongoing verbal cueing for safety, neuro check as indicated, anticipate, and attend to needs promptly, refer to rehab for evaluation and screening mat on floor. 3. 10/30/2021 at 2 p.m., SBAR indicated Resident 36 was noted on his buttocks on the floor mat. Resident 36 tried to get something out of his closet and stood up, walked a few steps, and sat on the 555112 Page 5 of 32 555112 12/06/2021 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0656 Level of Harm - Minimal harm or potential for actual harm floor mat. Charge nurse heard resident call out for help from room [ROOM NUMBER]. Care plan interventions included to assess Resident 36 after the fall, keep call light within reach, ongoing verbal cueing for safety, neuro check as indicated, anticipate, and attend to needs promptly, refer to rehab for evaluation and screening. Residents Affected - Some 4. 11/2/2021 at 2:30p.m., SBAR indicated Resident 36 was on his buttocks on the floor mat, certified nursing assistant (CNA) called charge nurse, charge nurse entered room [ROOM NUMBER] noted resident sitting on his buttocks on the floor mat. Care plan interventions included to assess resident after the fall, keep call light within reach, ongoing verbal cueing for safety, neuro check as indicated, anticipate, and attend to needs promptly, refer to rehab for evaluation and screening, re-educate resident to use call light and wait to be assisted. 5. 11/5/2021 at 7:00p.m., SBAR indicated Resident 36 was trying to transfer from wheelchair to bed without calling for help and lost his balance falling on his buttocks. Care plan interventions included to assess resident after the fall, keep call light within reach, ongoing verbal cueing for safety, neuro check as indicated, anticipate, and attend to needs promptly, refer to rehab for evaluation and screening, mat on floor. 6. Care plan dated 9/15/2021 indicated observed Resident 36 dangling on the side of his bed with pants down and ended up kneeling on the floor while holding onto his wheelchair. Care plan interventions included to assess Resident 36 after the fall, keep call light within reach, ongoing verbal cueing for safety, neuro check as indicated, anticipate, and attend to needs promptly, refer to rehab for evaluation and screening, educate/ remind resident to use call light and wait to be assisted. During an interview on 12/6/2021 at 9:18 a.m. with Minimum Data Set nurse (MDS), MDS stated that falls should have an SBAR, care plan, Interdisciplinary Team meeting conducted, rehab screening, fall assessment updated and pain assessment updated. MDS acknowledged Resident 36 kept falling because the care plan interventions were never updated or changed after each fall. MDS stated that it is almost the same interventions each time resident falls, so the problem was not addressed properly to prevent resident from repeatedly falling. During a review of Policy and Procedure (P/P) titled Fall Prevention Program dated December 2016, P/P indicated the facility will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. All residents will be assessed following incident of fall. Plan of care revision: A resident's condition and the effectiveness of the plan of care interventions will be evaluated if revisions are necessary to justify for continuing the existing plan. During a review of Policy and Procedure (P/P) titled Comprehensive Plan of Care dated December 2016, P/P indicated the comprehensive plan of care will include: Address the resident's individual needs, strengths and preferences; reflect current standards of professional practice, include treatment goals with measurable objectives, include interventions to 555112 Page 6 of 32 555112 12/06/2021 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0656 attempt to manage risk factors. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 555112 Page 7 of 32 555112 12/06/2021 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 licensed nursing staff failed to meet professional standards of quality for two (Resident 36 and 10) of the 14 sampled residents by failing to: Residents Affected - Few 1.Failing to ensure Resident 36's fall interventions in the care plan were properly updated after multiple falls (10/13/2021, 10/18/2021,10/30/2021,11/2/2021,11/5/2021). 2.Failing to ensure Resident 10's scratch was assessed, care planned and documented properly in a timely manner. Findings: A review of Resident 36's Face sheet indicated the resident was admitted to the facility on [DATE], with diagnoses that included diabetes mellitus (an impairment in the way the body regulates and uses sugar [glucose] as a fuel), history of falling, chronic pulmonary edema (pulmonary edema is usually caused by a heart condition), and unsteadiness on feet. A review of Resident 36's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 11/22/2021, indicated that Resident 36 was cognitively (ability to make decisions of daily living) intact and could make self-understood and had the ability to understand others and required extensive assistance with transfer, getting dressed, toilet use, and personal hygiene. During a concurrent observation and interview on 11/30/2021 at 3:32 p.m., Resident 36 stated that facility staff did not answer the call lights in a timely manner, as a result, Resident 26 stated he had multiple falls trying to reach the urinal by himself. A review of Situation, Background, Appearance, Review and Notify (SBAR- internal document for change of condition documentation) and care plan dated: 1. 10/13/2021 at 12:50p.m. indicated Resident 36 fell. According to the SBAR, Resident 36 was found on the floor inside his restroom and was transferred to the Emergency Room, interventions indicated to assess resident after the fall, keep call light within reach, ongoing verbal cueing for safety, neuro check (an assessment of the nervous system {the way various body parts communicate with each other] as indicated, anticipate, and attend to needs promptly, refer to rehab for evaluation and screening, Continue to educate/remind resident to use call light and wait for assistance. 2. 10/18/2021 at 12 p.m., SBAR indicated Resident 36 was noted on his right knee on floor mat. Care plan interventions included to assess resident after the fall, keep call light within reach, ongoing verbal cueing for safety, neuro check as indicated, anticipate, and attend to needs promptly, refer to rehab for evaluation and screening mat on floor. 3. 555112 Page 8 of 32 555112 12/06/2021 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0658 Level of Harm - Minimal harm or potential for actual harm 10/30/2021 at 2 p.m., SBAR indicated Resident 36 was noted on his buttocks on the floor mat. Resident 36 tried to get something out of his closet and stood up, walked a few steps, and sat on the floor mat. Charge nurse heard resident call out for help from room [ROOM NUMBER]. Care plan interventions included to assess Resident 36 after the fall, keep call light within reach, ongoing verbal cueing for safety, neuro check as indicated, anticipate, and attend to needs promptly, refer to rehab for evaluation and screening. Residents Affected - Few 4. 11/2/2021 at 2:30p.m., SBAR indicated Resident 36 was on his buttocks on the floor mat, certified nursing assistant (CNA) called charge nurse, charge nurse entered room [ROOM NUMBER] noted resident sitting on his buttocks on the floor mat. Care plan interventions included to assess resident after the fall, keep call light within reach, ongoing verbal cueing for safety, neuro check as indicated, anticipate, and attend to needs promptly, refer to rehab for evaluation and screening, re-educate resident to use call light and wait to be assisted. 5. 11/5/2021 at 7:00p.m., SBAR indicated Resident 36 was trying to transfer from wheelchair to bed without calling for help and lost his balance falling on his buttocks. Care plan interventions included to assess resident after the fall, keep call light within reach, ongoing verbal cueing for safety, neuro check as indicated, anticipate, and attend to needs promptly, refer to rehab for evaluation and screening, mat on floor. 6. Care plan dated 9/15/2021 indicated observed Resident 36 dangling on the side of his bed with pants down and ended up kneeling on the floor while holding onto his wheelchair. Care plan interventions included to assess Resident 36 after the fall, keep call light within reach, ongoing verbal cueing for safety, neuro check as indicated, anticipate, and attend to needs promptly, refer to rehab for evaluation and screening, educate/ remind resident to use call light and wait to be assisted. During an interview on 12/6/2021 at 9:18 a.m. with Minimum Data Set nurse (MDS), MDS stated that falls should have an SBAR, care plan, Interdisciplinary Team meeting conducted, rehab screening, fall assessment updated and pain assessment updated. MDS acknowledged Resident 36 kept falling because the care plan interventions were never updated or changed after each fall. MDS stated that it is almost the same interventions each time resident falls, so the problem was not addressed properly to prevent resident from repeatedly falling. During a review of Policy and Procedure(P/P) titled Fall Prevention Program dated December 2016, P/P indicated the facility will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. All residents will be assessed following incident of fall. Plan of care revision: A resident's condition and the effectiveness of the plan of care interventions will be evaluated if revisions are necessary to justify for continuing the existing plan. B. According to admission record, Resident 10 was admitted on [DATE], with diagnoses that included anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear strong enough to interfere with one's daily activities), hyperlipidemia (a condition in which there are 555112 Page 9 of 32 555112 12/06/2021 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few high levels of fat particles (lipids) in the blood), hypertensive chronic kidney disease (high blood pressure caused by the narrowing of the blood vessels that carry blood to the kidneys). A review of Resident 10's MDS dated [DATE], indicated Resident 10 had clear speech and was able to understand others and was able to be understood. Resident 10 required extensive one-person physical assist with bed mobility, transfers, getting dressed, toilet use, personal hygiene, and bathing, Resident 10 was unable to walk in the room or walk in the corridor. Resident 10's mood interview coded yes on the little interest or pleasure in doing things in the last several days. During an initial tour on 11/30/2021 at 10:11 am, Resident 10 stated that he was not aware that he had a scratch until 11/29/21, when Certified Nursing Assistant 3 (CNA 3) gave him a shower and informed Resident 10 that he had a scratch; Resident 10 then took a of picture of his scratch with his personal phone. During a record review of stop and watch binder (a binder with documentation of anything new or unusual findings with a Resident) for station 2, for the month of November 2021, there was no documented evidence of any scratch on Resident 10. During a record review of the shower sheet dated 11/29/2021, the document indicated Resident 10 had a scratch on his right buttock; and document was signed by Licensed Vocational Nurse 3 (LVN 3). During a concurrent interview and record review of Resident 10's shower sheet dated 11/29/2021, on 12/1/2021 at 11:13 am, LVN 3 stated that the shower sheet indicated whatever CNA 3 saw during Resident 10's shower day. Per LVN 3, generally, the CNAs documented findings on the sheet and the charge nurse validated by co- signing. LVN 3 stated, then she would have informed the treatment nurse (TX). LVN 3 confirmed Resident 10 had no documentation regarding the scratch because she assessed Resident 10's scratch but she never documented her findings. During a concurrent interview and record review of Resident 10's shower sheet (dated 11/29/2021) on 12/1/2021 at 11:24 am, with TX, TX stated that if the finding of the CNA was something new, the charge nurse coordinated with the TX; and TX would initiate the Situation, Background, Assessment, Recommendation, (SBAR written communication tool that helps provide essential, concise information, usually during crucial situations. Per TX, she was not informed of Resident 10's shower sheet dated 11/29/2021, until the next day 11/20/2021. TX stated that she assessed Resident 10's skin and observed a healed scratch, so she did not initiate an SBAR nor care plan or any documentation because it was already healed. TX nurse added it was scar tissue but intact skin. During a concurrent interview and record review of Resident 10's medical records, on 12/2/2021 at 10:36 a.m. with Registered Nurse (RN)1, RN 1 stated that on 12/1/2021 after Resident 10 returned to the facility from his outpatient appointment, a body assessment was completed, and RN 1 noted a light scratch scar tissue on the right side of Resident 10's hip. During a review of Policy and Procedure (P/P) titled Abuse and Neglect dated July 2018, policy indicated the facility conducts resident pre- admission, admission, and ongoing assessments(screening) and care planning for appropriate interventions and monitoring of residents with needs and behaviors which might lead to conflict or neglect. 555112 Page 10 of 32 555112 12/06/2021 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

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 observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, for 2 of 8 sampled residents (Resident 3 and 34) by: Residents Affected - Few 1.Failing to ensure Resident 3's skin problem was assessed, documented and reported properly in timely manner. 2.Failing to ensure Resident 34's hearing problem was assessed, monitored and reported properly in timely manner. This deficient practice had the potential to negatively affect the residents' physical comfort and psychosocial well-being and delay treatment. Findings: A. During a review of Resident 3's admission Record, the admission record indicated Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of, but not limited to, cellulitis (a common bacterial skin infection) of abdominal wall, type 2 diabetes mellitus (an impairment in the way the body regulates and uses sugar (glucose) as a fuel), anemia (a condition in which one lacks enough healthy red blood cells to carry adequate oxygen to the body's tissues), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), Parkinson's disease (a brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination), functional quadriplegia (complete inability to move body due to severe disability), contracture (a permanent tightening of the muscles, skin, and nearby tissues that causes the joints to shorten and become very stiff) of right and left ankle, contracture of right and left hand. During a review of Resident 3's Minimum Data Set (MDS - a comprehensive assessment and screening tool) dated September 3, 2021, MDS indicated Resident 3 was severely cognitively (include thinking, knowing, remembering, judging, and problem-solving) impaired and required extensive assistance with bed mobility and total dependence with transfer, locomotion, getting dressed, eating (tube feeding), toilet use, personal hygiene, and bathing. During a concurrent observation and interview with certified nursing assistant (CNA) 4 on December 1, 2021, at 11:15 a.m., Resident 3 was lying on bed, both hands on her abdomen with a splint (device used to provide a constant stretch to the soft tissues surrounding a joint. It is most effective when used to increase motion of a joint) on her right hand. Resident 3 was awake, alert, oriented to name and non-verbal. Resident 3 was unable to follow instructions with short commands. CNA 4 acknowledged Resident 3 had a visible red mark along her right side of the neck. During an interview on December 3, 2021, at 11:30 a.m. CNA 4 stated she had seen the skin discoloration on the right side of the neck on December 1, 2021 and reported it to a charge nurse and she also stated that Resident 3 was seen rubbing her neck. CNA 4 stated that Resident 3 had no history of any scratching or rubbing her neck prior to that. During a review of nurse's notes dated December 1, 2021, there was no documentation written that 555112 Page 11 of 32 555112 12/06/2021 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0684 CNA 4 reported the skin problem to the charge nurse. Level of Harm - Minimal harm or potential for actual harm During concurrent observation and interview on December 3, 2021 at 11:28 a.m. with Restorative Nursing Assistant (RNA), RNA stated that Resident 3 had a pressure relief ankle /foot orthosis (devices to correct alignment or provide support) boots for her lower extremities and a splint to her right hand. RNA shown Resident 3's right hand was contracted, and RNA stated that Resident 3 cannot move her right hand and arm due to contracture, however, Resident 3's left hand and arm were able to move with minimal assistance from RNA. Residents Affected - Few During a review of Resident 3's Situation Background Appearance Review and Notify (SBAR- internal document for change of condition documentation) Communication Form, dated December 1, 2021, the SBAR indicated that the change in condition in Resident 3 was self-inflicted skin discoloration on right side of the neck and this condition had not occurred before. SBAR indicated no definitive description of skin discoloration. During a review of Resident 3's non-pressure skin condition report ( a report to generated to assess and document any skin injury that was not a pressure ulcer) dated December 3, 2021, the report indicated the assessment and report was not completed until two days after the skin discoloration happened on December 1, 2021, on Resident 3's neck. During an interview on December 3, 2021 at 1:47 p.m., TX stated that she noticed Resident 3 was rubbing the right side of her neck with her left hand. TX stated that this was the first time she saw Resident 3 do that and she saw reddish discoloration and she stated that looks like new to her. TX stated that it measured 2 cm but no open skin breakdown. Also, LVN stated that it was not normal for Resident 3. TX stated that she did an SBAR for the change of condition but did not do the incident report. TX acknowledged she should document the color, size, and description of the skin problem to have a base line prior for monitoring and treatment and to know if the condition was getting worse or getting well. During an interview on December 3, 2021, at 2:50 p.m., Director of Nursing (DON), confirmed that any unusual occurrences must be documented and investigated, an incident report must be done right away. DON stated that the Registered Nurse on duty must initiate all documentation such as Change of Condition (COC), SBAR and notifying physician and responsible party. DON stated that skin discoloration can be an unusual occurrence, depending on the location and the situation. DON stated that Resident 34's skin discoloration on the right side of the neck needed monitoring. DON confirmed that Resident 34 is not taking any anticoagulants (medication that prevent the blood from clotting as quickly or as effectively as normal, which can lead to easy bruising) medication. DON stated that anything that is not documented, it did not happen. During a review of Resident 3's care plan (CP) initiated on December 1, 2021, the care plan indicated a problem: risk for skin integrity related to skin discoloration, location right neck area, contributing factors were fragile skin and impaired mobility, with risks: infection, pain/comfort. Goal: will be healed in 30 days. Interventions: provide treatment as ordered: Monitor for skin breakdown, monitor signs of infection e.g., redness, presence of drainage, pain and report to the MD, evaluate treatment as needed: call MD and notify responsible party of changes, body check as required to monitor changes and response to treatment. During a review of facility's policy and procedure (P/P) release dated July 2020, titled Incident reporting for residents or visitors, P/P indicated that all accidents and unusual occurrences 555112 Page 12 of 32 555112 12/06/2021 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few involving a resident or visitor will be documented and reported to meet all regulatory (state, and federal) and insurance carrier requirements. Unusual occurrence or event: indicated any event not consistent with routine care. Procedures indicated that when an unusual occurrence is discovered the employee making the discovery will notify his or her immediate supervisor of the discovery. If the event requires immediate action from the Administrator, he or she will be notified immediately. The person discovering the event must complete the incident/accident report prior to completing the shift. During a review of facility's policy and procedures release date December 2017, titled Skin Breakdown, Prevention and Management, indicated that it is the goal of the nursing staff with the assistance of the interdisciplinary team (IDT) using the nursing process to identify, assess, plan, prevent, intervene and monitor progress of care for all residents at risks of developing and/or developed any type of pressure or non-pressure skin discoloration or breakdown. The purpose is to assure that all causes pressure or non-pressure skin discoloration and/or breakdown are investigated and documented in timely and thorough manner. B. During a review of Resident 34 's admission Record, the record indicated Resident 34 was admitted to the facility on [DATE] with diagnoses of, but not limited to, type 2 diabetes mellitus (an impairment in the way the body regulates and uses sugar (glucose) as a fuel, retention of urine, abnormal posture, muscle weakness, acquired absence of left leg below knee, and acquired absence of right leg below knee. During a review of Resident 34's MDS dated [DATE], the MDS indicated the Resident 34 was cognitively intact, and required extensive assistance with bed mobility, transfer, locomotion, getting dressed, toilet use, personal hygiene, and bathing. MDS also indicated that Resident 34 had adequate hearing ability. During a concurrent observation and interview on November 30, 2021, Resident 34 stated that he barely heard what this surveyor was saying, and he asked this surveyor to write my questions down, but Resident 34 did not have a communication white board at bedside that was available to use. Resident 34 stated that facility staff were aware he could not hear them for over a week. During a review of Charting Alert Log for Monitoring Resident's Condition logbook indicated that there was no record of hearing problem for Resident 34 as far as October 22, 2021. During an interview on December 3, 2021 at 2:50 p.m., DON verified that unusual occurrences, such as Resident 34's hearing difficulty must be documented and investigated, an incident report must be done right away. DON acknowledged that RN should have initiated all the documentation such as Change of Condition (COC), SBAR and notifying physician and responsible party. During a review of facility's P/P titled Change of Condition release dated August 2017, indicated that it shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident medical/mental condition and/or status (e.g. changes in level of care, billing/payments, resident rights, etc.). Acute changes or any sudden or serious change in condition manifested by a marked change in physical, mental and psychosocial status: notify and inform legal surrogate for any change of condition. Nurse's notes will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. 555112 Page 13 of 32 555112 12/06/2021 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow its own policy to ensure one of seven sampled residents (Resident 14) who had a limited range of motion (ROM - movement of the joints within normal limits) received the appropriate treatment and services to increase, maintain or prevent decline of the ROM mobility for one of seven residents (Resident 14). This deficient practice had the potential to result in a decrease in ROM of resident 14's limbs and increase the risk of contracture (muscle shortening, often accompanied by pain, and loss of range of motion) and physical decline. Findings: A review of the Face sheet indicated Resident 14 was admitted to the facility on [DATE], with diagnoses that included Type 2 Diabetes mellitus (the body's inability to process and use sugar) with Diabetic Nephropathy (a type of kidney nerve damage that can occur due to diabetes), Pressure ulcer right hip (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) Chronic Kidney disease (inability of kidneys to fully function). A review of Resident 14's Minimum Data Set (MDS-a comprehensive screening and care planning tool) dated 09/20/2021, indicated Resident 14 had the ability to make himself understood and understand others; MDS indicated Resident 14's cognition (ability to make decisions of daily living) was moderately impaired. MDS indicated Resident 14 needed extensive assistance with bed mobility, transfer from and to the bed, locomotion on and off unit, getting dressed, toilet use, personal hygiene, and bathing. MDS also indicated Resident 14 in ROM no impairment on both upper and lower extremities in range of motion. During an interview on 12/2/2021 at 2:04 p.m. with Licensed Vocational Nurse 3 (LVN3), LVN 3 stated in the past Resident 14 used to sit at the edge of the bed, but now was no longer able to. LVN 3 stated Resident 14 was able to use his wheelchair in the hallways of the facility and now rarely does. During an interview on 12/2/21 at 3:26 p.m. with Occupational Therapist (OT; a physical therapist that provides therapy to maintain or increase ability to perform ADL's), OT acknowledged that she did not assess Joint Mobility assessment/ Screening of Resident 14 to recommend restorative nursing assistant (RNA; a type of nursing assistant trained to help nurses in restoring mobility to residents) services. OT stated that one of the benefits of ROM therapy with an RNA is to prevent the physical decline of Resident 14 in performing ADL's. OT acknowledged Resident 24 could have a functional decline in mobility and worse can get contractures due to not getting RNA services. During a review of Policy and Procedure (P/P) titled, Standards for Restorative Nursing Program dated September 2019 indicated, Restorative Nursing Program is a service provided by the facility generally under nursing, to ensure maintenance of a patient's optimum level of function. The patients on this program are encouraged or assisted to achieve and maintain their highest level of self-care and independence. 555112 Page 14 of 32 555112 12/06/2021 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that one of 8 sampled residents (Resident 27), who was receiving nutrition by gastrostomy tube (GT - a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration), was provided service to prevent aspiration by failing to ensure the resident's head of the bed was elevated during feeding. This deficient practice placed Resident 27 at risk for aspiration (inhaling small particles of food or drops of liquid into the lungs) while receiving nutrition by gastrostomy tube that can lead to lung infections such as pneumonia. Findings: A review of Resident 27's admission record indicated, Resident 27 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of sepsis (an infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever), dysphagia (difficulty swallowing), type 2 diabetes mellitus (an impairment in the way the body regulates and uses sugar [glucose] as a fuel). During a review of Resident 27's Minimum Data Set (MDS - a comprehensive assessment and screening tool) dated October 15, 2021, MDS indicated Resident 27 was severely cognitivly (ability to understand and make decisions of daily living) and required extensive assistance with bed mobility and getting dressed. MDS also indicated Resident 27 was totaly dependendent with transfers (in and out of bed), eating (tube feeding), toilet use, personal hygiene, and bathing. During a review of Resident 27's physician's order, dated April 30, 2021, the order indicated to elevate (raise) the head of the bed at 30 to 45 degrees at all times (to prevent aspiration). During concurrent observation and interview on November 30, 2021 at 2:54 p.m., Resident 27 was lying in bed with the head of the bed almost laying flat with small amounts of white fluids coming out of thecorners of his mouth. Resident 27 was connected to a GT formula that was infusing (on). LVN 1 stated that the head of bed of Resident 27 was almost lying flat. LVN 1 elevated the head of the bed to 30 degrees. LVN 1 wiped Resident 27's mouth to remove the white fluids. LVN 1 confirmed that Resident 27's head of bed should be elevated to 35 degrees to prevent aspiration of the feeding. During a review of the facility's policy and procedure (P/P), dated December 2017 titled Enteral Feeding via Pump Administration, P/P indicated the purpose of the procedure is to provide nourishment to the resident who is unable to obtain nourishment orally. Monitor resident for signs and symptoms of aspiration and/or feeding intolerance. Report complications promptly to the supervisor and attending physician. Enteral nutrition will be administered in a safe and effective manner to prevent complications and maintain or improve the residents' hydration and nutrition status. According to the National Health Institute (NIH; an agency primarly responsbile for public health research) indicated that raising the head of the bed is an intervention that can reduce the occurance of aspiration, and aspiration-related pneumonia effectively (https://pubmed.ncbi.nlm.nih.gov/20010041/) 555112 Page 15 of 32 555112 12/06/2021 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure proper use of bed rails (are adjustable metal or rigid plastic bars that attach to the bed) for one of 7 sampled residents (Resident 36), as indicated in the facility's policy and procedure by failing to: 1. Ensure the Informed consent was properly completed with specific medical symptoms, indication, patient ' s name, policy and name of device before Resident 36 signed it. 2. Ensure the date of the physician's order date was on the same day as the consent date and the bed rail risk screen assessment tool for use of bed rails. These deficient practices had the potential to result in inappropriate use of bed rails for Resident 36 leading to injuries. Findings: A review of Resident 36's Face sheet indicated the resident was admitted to the facility on [DATE], with diagnoses that included diabetes mellitus (a disease in which your blood sugar levels are too high), history of falling, and unsteadiness on feet. A review of Resident 36's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 11/22/2021, indicated that Resident 36 was cognitively intact and could make self-understood, had the ability to understand others and required extensive assistance with transfers, getting dressed, toilet use, personal hygiene, and total assistance with bathing. A review of Resident 36's History and Physical (H&P) dated 6/7/2021, indicated that Resident 36 had the capacity to understand and make decisions. During a concurrent observation and interview 11/30/2021 at 3:32 p.m., Resident 36 ' s bed had both 1/3 rails up. During a review of the physician's order dated 6/4/2021 the order indicated, apply bilateral (both sides) 1/3 siderails while resident is in bed to aid in repositioning, bed mobility and aid during transfer, consent given after risk and benefits explained order dated 06/4/2021. A review of the bed rail risk screen (a tool for assessing if Resident is a candidate for bed rails) dated 10/14/2021 (more than four months after the physician's order to use siderails dated 6/7/2021). During a review of Device/Restraint Assessment and Reduction Management Program the review date was 10/14/2021 (more than four months after the physician's order to use siderails). During a review of care plan dated 6/14/2021 initial date and reevaluated 9/2021 and 12/21 with intervention of keep call light within reach, bed at right height, review the risk and benefits of bed rails with resident, ensure that the beds dimensions are appropriate, bed system modification 555112 Page 16 of 32 555112 12/06/2021 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0700 device. Level of Harm - Minimal harm or potential for actual harm During a review of informed consent dated 11/19/2019 for the use of physical restraints policy of underlined/blank, on bottom it indicated give consent that underlined/blank restraint may be used for the purpose underlined/blank on the medical symptom and patients name is underlined/blank as well, signed by Resident 36. Residents Affected - Few During an interview on 12/6/2021 at 9:18a.m. with MDS nurse, MDS nurse stated that consent should be obtained along with the physician's order, risk assessment tool and care plan at the same time. MDS confirmed the consent form should have been completed, after Resident 36 was educated of the risks and benefits of using side rails, and before he signed it. During a review of Policy and Procedure (P/P) titled Bed Rail Assessment and Management dated December 2016, the P/P indicated, before a resident uses bed siderail, the physician and the inter-disciplinary (IDT) team must determine the presence of a specific medical symptom that would require its use, and how it will assist in treating the medical symptom, the medical symptoms that warrant the use of bedside rails shall be documented in the resident's medical record, ongoing assessments 555112 Page 17 of 32 555112 12/06/2021 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure a medication error rate of less than five (5) percent, due to improper medication administration for two (2) of four (4) randomly selected residents (Resident 5 and 10). The outcome was five (5) medication errors out of twenty-five opportunities for errors, which resulted in a medication administration error Rate of twenty (20) percent, that exceeded the five(5) percent threshold. Residents Affected - Many Findings: a.During a record review of Resident 5's admission record (face sheet), the face sheet indicated the facility admitted Resident 5 on 9/10/2021 with diagnoses including, acute chronic congestive heart failure (heart does not pump efficiently) and chronic venous hypertension with ulcer of left lower extremity (high blood pressure[elevated force of blood] inside the left leg and ulcers [sores] form in the leg). A review of the minimum data set (a standardized assessment and care screening tool [MDS]), dated 9/18/2021, indicated Resident 5 had intact cognitive skills (the core skills your brain uses to think, read, learn, remember, reason, and pay attention) for daily decision making. The MDS further indicated that Resident 5 needed supervision in eating and one person assistance with activities of daily living ([ADLs] tasks of everyday life, getting dressed, getting into or out of a bed or chair, taking a bath or shower, toileting). During a concurrent medication pass observation, interview and record review of Resident 5's medication bubble packs (pre-packaged cared with doses of medication in small clear plastic bubbles or compartments marked for medication to be taken at specific times of the day) with licensed vocational nurse 2 (LVN 2) on 12/1/2021 at 8:16 AM, LVN 2 confirmed Resident 5 will be receiving the following medications: 1.One tablet (tab) of gemfibrozil (medication to lower lipids) 600 milligrams (mg- a unit of measure) by mouth (PO); and 2.One tablet of potassium chloride (a supplement [KCl]) 20 milliequivalent (meq: concentration of the supplement in a liter of fluid), PO. Per LVN 2, the gemfibrozil had specific instructions to be taken on an empty stomach twice daily for hyperlipidemia. During the continued medication pass observation and interview with LVN 2 on 12/1/2021 at 8:26 AM, LVN 2 verbally confirmed and then administered the following medications to Resident 5: 1.One tablet of gemfibrozil 600 mg by mouth PO; and 2.One tablet of potassium chloride 20 meq PO. During an interview with Resident 5 on 12/1/2021 at 8:27 AM, Resident 5 stated he had had an omelet and cereal for breakfast today a little after 7:00 AM. 555112 Page 18 of 32 555112 12/06/2021 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a concurrent interview and record review of Resident 5's bubble pack for gemfibrozil on 12/3/2021 at 11:06 AM, LVN 2 confirmed and stated that the medication label indicated the gemfibrozil needed to be administered on an empty stomach. Per LVN 2, she should not have administered the gemfibrozil to Resident 5 at that time. LVN 5 stated she should have either given it 2 hours after consuming breakfast or she should have not given it without clarifying with the pharmacist whether the medication needed to be administered on an empty stomach or not. During a concurrent interview and record review of Resident 5's summary of physician orders dated 12/2021, a bubble pack for KCl and Resident 5's medication administration record (MAR) for KCl for September to December 2021 on 12/3/2021 at 11:06 AM, registered nurse 1 (RN 1) confirmed the following: 1.Resident 5's summary of physician order for December 2021 indicated an order for KCl 20 micrograms (mcg: one millionth of a gram [a unit of measurement of weight]). 2.The medication (to be administered to Resident 5), was labeled as KCl 20 meq PO daily. Per RN 1, the physician order, MAR, and KCl bubble pack label should all have matching doses. Per RN1, it should have been clarified with the physician or the original handwritten physician's order. Per RN1, there were eighty-one (81) missed opportunities when staff could have clarified and confirmed the order by calling the pharmacist, physician or clarifying with the original handwritten order for KCl. Per RN1 it was important to ensure medications were transcribed and administered to residents as originally ordered to ensure resident was receiving the correct dose and the intended treatment. b.During a record review of Resident 10's face sheet, the face sheet indicated the facility admitted Resident 10 on 5/24/2021 with diagnoses including type 2 diabetes (bodies inability to processes sugar) with neurological complication (nerve damage mostly in legs or feet), complete traumatic amputation of left great toe (loss of the left great toe, due to accident), osteomyelitis (bone infection) of left ankle and foot. A review of Resident 10's MDS, dated [DATE], indicated Resident 10 had the ability to express ideas and wants, and the ability to understand others. Further review indicated Resident 10 had intact cognitive skills for daily decision making. The MDS further indicated that Resident 10 needed supervision in eating and one person assistance with activities of daily living. During a record review of Resident 10's summary of physician orders dated 12/2021, and Resident 10's MAR, the record indicated a medication order, started on 5/28/2021, for Percocet (pain medication): 1.Dosage on orders for percocet was 10-325 milligrams (mg) but the MAR indicated 5-325 mg (a smaller dosage). 2.The order for frequency for administration of the Percocet, indicated every 6 hours as needed (PRN) for severe pain of left foot status post amputation however the MAR indicated every 4 hours PRN (more frequently than ordered) for moderate to severe pain. During a concurrent medication pass observation and interview with LVN 3 on 12/1/2021 at 8:59 AM, LVN 3 confirmed Resident 10 will be receiving one (1) tablet of Percocet, PO, 5/325 mg. Per LVN 3, 555112 Page 19 of 32 555112 12/06/2021 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many the Percocet was last given to Resident 10 on 12/1/2021 at 4:20 AM. (5 hours and 40 minutes ago). LVN 3, verified the medication label, and MAR, the instructions indicated Percocet 5/325 mg, one (1) tab as needed (PRN) every four (4) hours for moderate to severe pain. After confirming all the information, LVN 3 administered 1 tablet of Percocet 5-325 mg. PO to Resident 10. During an interview with the director of nursing (DON) on 12/3/2021 at 2:47 PM, the DON confirmed medication administration was an important part of resident care and the nurses needed to ensure they administered medications accurately. Per DON, physician orders, MAR, and the bubble pack medication labels all needed to match to ensure residents were receiving accurate treatment as prescribed by their medical provider. DON acknowledged it was unsafe for Resident 5 and 10 to get medication in the wrong dose, the wrong frequency or the wrong form. During a record review of the undated facility's policy entitled, Medication administration general guidelines for the administration of medications, indicated the facility staff will provide safe and accurate medication administration to the residents. The procedure indicated, nursing reviews each resident's MAR to determine which medications need to be administered at the given time. The nurse observes the five rights in administering each medication which included the right time and the right dose. 555112 Page 20 of 32 555112 12/06/2021 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure one (1) of four (4) randomly selected residents (Resident 10) was free from significant medication errors (one which could cause the resident discomfort or jeopardize his or her health and safety) when the facility administered the incorrect dosage and incorrect frequency of Percocet (a prescription pain medication) as ordered by the physician for Resident 10. Residents Affected - Few These deficiencies placed Resident 10 at a higher risk for increased untoward side effects of Percocet which included nausea, vomiting, fatigue, dizziness, and low blood pressure (pressure of blood in the body). FINDINGS: During a record review of Resident 10's admission record (face sheet), dated 10/15/2021, face sheet indicated the facility admitted Resident 10 on 5/24/2021 with a diagnosis including type 2 diabetes (problem of the way the body processes sugar [glucose]) with other neurological complication (nerve damage mostly in legs or feet), complete traumatic amputation (surgical removal) of left great toe, osteomyelitis (bone infection) left ankle and foot. During a review of Resident 10's minimum data set (a standardized assessment and care screening tool [MDS]), dated 9/29/2021, the MDS indicated Resident 10 had the ability to express ideas and wants, and had the ability to understand others. Further review indicated Resident 10 had intact cognitive skills (the core skills your brain uses to think, read, learn, remember, reason, and pay attention) for daily decision making. The MDS further indicated that Resident 10 needed supervision in eating and one person assistance with activities of daily living ([ADLs] tasks of everyday life, getting , getting into or out of a bed or chair, taking a bath or shower and using the toilet). During a record review of Resident 10's recapitulation (summary) of physician orders for 12/2021 and Residents 10's medication administration record (MAR), Resident 10's Percocet order, which started on 5/28/2021, indicated a discrepancy between the MAR and physician orders: 1. In the orders, Percocet dosage was for 10-325 milligrams (mg) and the MAR indicated 5-325 mg; and 2. Per orders, Percocet was to be administered every six (6) hours as needed (PRN) for severe pain of left foot status post amputation and Resident 10's MAR indicated every four (4) hours PRN for moderate to severe pain. During a concurrent medication pass observation and interview with LVN 3 on 12/1/2021 at 8:59 AM, LVN 3 confirmed Resident 10 will be receiving one (1) tablet of Percocet, PO, 5/325 mg. Per LVN 3, the Percocet was last given to Resident 10 on 12/1/2021 at 4:20 AM. (5 hours and 40 minutes ago). LVN 3, verified the medication label, and MAR, the instructions indicated Percocet 5/325 mg, one (1) tab as needed (PRN) every four (4) hours for moderate to severe pain. After confirming all the information, LVN 3 administered 1 tablet of Percocet 5-325 mg. PO to Resident 10. Per LVN 3, the physician order, MAR, and medication label all must indicate the same dose and frequency as it was facility 555112 Page 21 of 32 555112 12/06/2021 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0760 policy. Level of Harm - Minimal harm or potential for actual harm During an interview with the director of nursing (DON) on 12/3/2021 at 2:47 PM, the DON confirmed medication administration was an important part of resident care and the nurses needed to ensure they administered medications accurately. Per DON, physician orders, MAR, and the bubble pack medication labels all needed to match to ensure residents were receiving accurate treatment as prescribed by their medical provider. DON acknowledged it was unsafe for Resident 5 and 10 to get medication in the wrong dose, the wrong frequency, or the wrong form. Residents Affected - Few During a record review of the undated facility's policy entitled, Medication administration general guidelines for the administration of medications , policy indicated the facility staff will provide safe and accurate medication administration to the residents. The procedure indicated; the nurse reviews each resident's MAR to determine which medications needed to be administered at a given time. The nurse observes the five rights in administering each medication which included the right time and the right dose. 555112 Page 22 of 32 555112 12/06/2021 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 one (1) of three (3) Intravenous (administered into the veins [IV]) emergency kit (set of medications used for giving emergency treatment [E-kit]) was refille as soon as possible, for one of one medication storage areas. The deficient practice had the potential to result in an insufficient number of medications on hand in case of an emergency. FINDINGS: During a concurrent observation, interview, and record review of medication order form for an E-kit on 12/1/2021 at 9:19 AM, registered nurse 1 (RN 1) confirmed the E-Kit for IV had been opened and five (5) items were missing in the kit: 1. One (1) liter Normal Saline ( IV medication for fluid and electrolyte [minerals in the body] replenishment[NS]), 2. Rocephin (medication that inhibits or destroys microorganisms [germs]) one (1) gram (a unit of measure) 3. Two hundred (200) milliliter bag of NS, and 4. Two (2) one liter bags of 0.45 percent concentration of NS. Further review of the medication E-kit order form with RN 1 during the medication storage inspection, the forms indicated: 1. NS (1 liter) was removed on 11/5/2021, 2. Rocephin was removed on 11/11/2021, 3. 555112 Page 23 of 32 555112 12/06/2021 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0761 NS (200 milliliter bag) was removed on 11/11/2021, and Level of Harm - Minimal harm or potential for actual harm 4. the 0.45 percent of NS was removed on 11/12/2021. Residents Affected - Some Per RN 1, the E-kit should have been replenished when it was first opened on 11/5/2021. Per RN 1, they should have had it replaced within 72 hours. During an interview with director of nursing (DON) on 12/3/2021 at 7:40 AM, DON acknowledged the E-Kit still needed to be replaced. Per DON, as a standard of nursing practice, facility staff should notify the pharmacy right away to ensure the contents of the E-Kit were replaced in a timely manner to avert insufficient supplies during an emergency. During a record review of the undated facility's policy entitled, Medication dispensing emergency drug kit, the purpose was to ensure a selection of medications were available in the facility for immediate use. Per policy, the used emergency drug kit will be returned to the pharmacy to be restocked, sealed, and then returned to the facility. 555112 Page 24 of 32 555112 12/06/2021 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 ensure to kitchen equipment in a sanitary manner to prevent growth of microorganisms that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins) for 56 residents in the facility by: 1. Failing to ensure the fan in the food preparation area was clean. 2. Failing to ensure staff member used a clean handheld mixer in food preparation. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea and fever which can lead to other serious medical complications and hospitalization. Findings: During an observation on December 1, 2021 at 8:42 a.m., in the kitchen, the fan on top of the microwave in the preparation for residents food area was covered with gray to black dusty matter on fan's blades., and a dusty radio on top of kitchen warmer was observed. During an observation on December 1, 2021 at 8:50 a.m. in the kitchen, [NAME] 2 observed got a handheld mixer from the utensil shelf and accidentaly dropped it into a dirty sink then picked it up and used it to mix the pureed (food cooked, and blended to the conisistency of a creamy paste or liquid) food in the container without washing the hand held mixer. During an interview on December 1, 2021 9:25 a.m., Dietary Supervisor (DS) stated that all kitchen staff had in-service training regarding sanitation and infection control for Kitchen. During a review of the facility's policy and procedure dated 2018 titled Sanitation, indicated that the food and nutrition services department shall have equipment of the type and in the amount necessary for the proper preparation, serving and storing of food. There shall be adequate equipment for cleaning, disposal of waste and general storage. All equipment shall be maintained as necessary and kept in working order. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks and chipped areas. No radios allowed in the kitchen. 555112 Page 25 of 32 555112 12/06/2021 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview and record review the facility's Quality Assessment and Assurance Committee (QA&A), failed to implement corrective action to the systemic problems identified, thereby affecting 56 out of 56 residents: a.ensure medication administration error rate was below five (5) percent. b.ensure the proper implementation of change of condition (COC) procedure. c.ensure staff maintained professional standards in assessing, documenting, monitoring, and creating meaningful interventions for residents plans of care. d.ensure the infection control program (preventative measures implemented to mitigate spread of infectious diseases) was efficient and being followed. As a result, the facility's deficient practices placed the residents at risk for not receiving the quality of treatment necessary to adequately meet their highest practicable well-being. FINDINGS: department of health that describes facility's deficiencies in complying with licensing laws or conditions of participation) for the 2019 recertification survey, form CMS 2567 indicated repeat deficiencies for the regulatory groupings: accuracy of assessments, services provided meet professional standards, and infection control. During a record review of the facility's last abbreviated (focused) survey completed on 11/11/2021, the 2567 indicated the facility received an immediate jeopardy ([IJ] a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) under the regulatory grouping, quality of care. During an interview with the administrator and the director of nursing (DON) on 12/6/2021 at 10:21 AM, the administrator and the DON acknowledged the facility should have showed improvement in regarding: e.Proper staff implementation of the change of condition of a resident (COC) facility protocol, specifically in addressing problems identified thoroughly, timely notification of the physician, and adequate monitoring of the issue/s identified. f.Screening of all staff, who enter the building for risk of coronavirus disease 2019 (highly contagious respiratory disease [covid-19]). g.Licensed nurses' poor adherence to professional standards when rendering resident care. Licensed nurses need to document to reflect the assessment, care, interventions provided. Licensed nurses need to be accurate in their assessments. 555112 Page 26 of 32 555112 12/06/2021 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0867 h.Medication administration error aversion. Level of Harm - Minimal harm or potential for actual harm Per DON and administrator, leadership was looking forward to revamping facility operations and correcting deficiencies identified to be able to serve residents and the community better. Residents Affected - Many During a record review of the facility's policy titled Quality assurance and performance improvement (QAPI) program (9/19/2019), policy indicated the primary goals of QAPI was to provide a structure and process to correct identified opportunities for improvement and establish benchmarks to measure outcomes. 555112 Page 27 of 32 555112 12/06/2021 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to follow and maintain an infection control program (program designed to prevent the spread of infection in the facility) for 56 out of 56 residents when: Residents Affected - Many a. Staff entered the facility without being screened for coronavirus disease 2019 (highly contagious respiratory disease [covid-19]), b. Licensed vocational nurse 5 (LVN 5) did not clean and sanitize the blood pressure cuff (medical device consisting of a piece of rubber wrapped around a resident's arm and then inflated to measure blood pressure [force of blood flowing in the veins]) in between residents, and when LVN 5 did not perform hand hygiene (a way of cleaning one's hands that substantially reduces bacteria [HH]) in between several residents, while taking resident's vital signs (measurements of the body's most basic functions, heart rate, respirations, blood pressure), and c. The treatment nurse (TX) did not follow aseptic technique (using practices and procedures to prevent contamination from pathogens [an organism that can cause disease]) when rendering wound treatment for Resident 14. Ran These deficient practices had the potential to result in the transmission of infections, including Covid-19, between all the residents in the facility, thereby threatening their health and wellbeing. Findings: a) During a record review of timesheets (time account of employees that worked in the facility) dated 11/20/2021, 11/21/2021, 11/27/2021, and 11/28/2021 for facility employees, the timesheets indicated: i. On 11/20/2021, 46 employees worked in the facility. ii. On 11/21/2021, 40 employees worked in the facility. iii. 555112 Page 28 of 32 555112 12/06/2021 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0880 On 11/272021 38 employees worked in the facility. Level of Harm - Minimal harm or potential for actual harm iv. On 11/28/2021 39 employees worked in the facility. Residents Affected - Many During a record review of the facility's daily screening logs (record noting the screening[series of questions asked to determine a person's risk for Covid-19] done on employees) indicated: i. On 11/20/2021, 36 employees were screened prior to entry to the facility, 10 were not screened prior to entry ii. On 11/21/2021, 27 employees were screened prior to entry to the facility, 13 were not screened prior to entry. iii. On 11/272021, 32 employees were screened prior to entry to the facility; 6 were not screened prior to entry. iv. On 11/28/2021, 28 employees were screened prior to entry to the facility and 11 were not screened prior to entry. During a concurrent interview with dietary aid 2 (DA 2) and record review of the daily screening logs dated 11/20/2021, 11/21/2021, 11/27/2021, and 11/28/2021 on 12/3/2021 at 11:28 AM, DA 2 confirmed that he did not get screened on those four days when he came to work. During a concurrent interview and record review of the facility daily screening log and employee time sheets on 12/3/2021 at 11:25 AM, the infection preventionist (IP) stated and confirmed DA 2, certified nurse assistant 8 (CNA 8), and licensed vocational nurse 3 (LVN 3) were not screened on varied days prior to working their shifts in the facility. During an interview and record review of daily screening log on 11/20/2021 and 11/27/2021 on 12/3/2021 at 12:17 PM, LVN 3 stated and confirmed she did not get screened prior to entering the facility on 11/20/2021 and 11/27/2021. During an interview and record review of daily screening log on 11/20/2021 and 11/27/2021 on 12/3/2021 at 12:17 PM, CNA 8 stated and confirmed he did not get screened prior to entering the facility on 11/20/2021 and 11/27/2021. During an interview with the administrator and the director of nursing (DON) on 12/6/2021 at 10:21 AM, the DON and the administrator both acknowledged the problem with staff screening prior to facility entry. Per DON, screening prior to entry to the facility, was vital in mitigating the spread of 555112 Page 29 of 32 555112 12/06/2021 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0880 Covid -19, amongst facility residents, staff, and the community. Level of Harm - Minimal harm or potential for actual harm During a record review of the facility's policy titled guidance for infection prevention and control for residents with suspected or confirmed Covid-19 (8/3/2020), policy indicated preventing exposure and transmission of SARS-CoV-2 ( virus that causes COVID-19) was paramount at nursing centers, where many residents were more vulnerable to complications from the novel disease because of chronic health problems and weakened immune systems. Per policy, all staff will be screened for signs and symptoms of SARS-CoV-2 infection prior to starting their shift. Residents Affected - Many During a record review of the Skilled Nursing Facilities B73 Covid-19 - Procedural Guidance for Department of public health (DPH) Staff (guidelines from the Department of Public Health, that outline actions that Skilled Nursing Facilities (SNFs) should take to help prevent and manage COVID-19) updated 10/27/2021, the manual indicated all persons, regardless of vaccination status, should be screened for signs and symptoms of COVID-19 infection, including temperature checks prior to entering the facility. Additionally, all persons who are partially vaccinated or unvaccinated should be screened for any recent travel outside of California in the past 14 days. Per guidance, all staff should be screened at least once per shift. b)During a record review of the minimum data set (a standardized assessment and care screening tool [MDS]), dated 9/27/2021, the MDS indicated the facility admitted Resident 7 on 7/18/2021. Per MDS, Resident 7 had the ability to express ideas and wants and had the ability to understand others. Further review indicated Resident 7 had moderately impaired cognitive skills (the core skills your brain uses to think, read, learn, remember, reason, and pay attention) for daily decision making. The MDS further indicated that Resident 7 needed supervision in eating and required extensive assistance to total dependence with activities of daily living ([ADLs] tasks of everyday life, getting dressed, getting into or out of a bed or chair, taking a bath or shower and using the toilet). During a record review of MDS dated [DATE], the MDS indicated the facility admitted Resident 12 on 2/11/2020. Per MDS, Resident 12 had the ability to express ideas and wants and had the ability to understand others. Further review indicated Resident 12 had intact cognitive skills for daily decision making. The MDS further indicated that Resident 12 needed supervision in eating and required supervision to limited assistance with ADLs. During a concurrent observation and interview with LVN 5 on 11/30/2021 at 3:15 PM, LVN 5 was observed taking Resident 7's vital signs then preceding to take Resident 12's vital signs without hand sanitizing or washing hands and without sanitizing the blood pressure apparatus. LVN 5 was further observed entering rooms [ROOM NUMBER], checking more residents vital signs without any gloves on. LVN 5 stated she only used gloves during medication administration or when doing any sort of treatment, but not when checking vital signs. Per LVN 5, she confirmed not performing hand hygiene upon entering or leaving residents rooms, and before and after vital signs were checked. LVN 5 also confirmed not sanitizing the blood pressure machine after every use. c.A review of the face sheet indicated Resident 14 was admitted to the facility on [DATE], with diagnoses that included, Diabetes Mellitus (an illness that causes inability to process and use sugar), hypertension (high blood pressure) and hypertensive chronic kidney disease with Stage 4 (damage to the kidney function caused by hypertension). During a review of Resident 14's MDS dated [DATE], the MDS indicated Resident 14 had the ability to express ideas and wants and had the ability to understand others. Further review indicated Resident 555112 Page 30 of 32 555112 12/06/2021 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 14 had moderately impaired cognitive skills for daily decision making. The MDS further indicated that Resident 14 needed supervision in eating and required extensive assistance to total dependence with activities of daily living. During an observation of Resident 14's wound treatment on 12/1/2021 at 9:31 AM, TX did not wash her hands when going between clean and dirty fields (areas with no or minor contamination and areas with higher amount of potential contamination) while rendering wound care and not changing her gloves during six (6) different missed opportunities: a. After cleansing right side of the wound on the outer knee, TX used the same dirty gloves and did not wash her hands to apply a new clean gauze pad (material used for wound dressing) on the wound. b. After cleansing the sacral (tail bone) wound, TX used the same dirty gloves and did not perform HH prior to applying a new clean gauze to cover the wound. c. After cleansing Resident 14's right upper thigh wound, TX used same contaminated gloves to apply a new dressing and she did not wash her hands. d. After cleansing toes on the right side of Resident 14's foot, TX used the same dirty gloves to apply a new clean gauze pad on the wound and she did not wash her hands. e. After Resident 14's wound treatment, TX placed items away, she did not wash her hands and she used dirty gloves to recap Tetracyte topical (to be applied on skin) spray (solution to prevent the risk of skin infection). f. After wound care treatment, TX used the same dirty gloves to moisturize both of Resident 14's legs with A &D ointment (vitamin a and d protective ointment). During a follow up interview with TX on 12/03/2021 at 10:52 AM, TX confirmed after handling the wound in the dirty field, TX should have removed soiled gloves, washed hands, put on new clean gloves prior to covering the wound with a clean dressing as ordered. During a record review of the facility's policy, Clinical procedures standard (dated 8//2017), policy indicated the policy was to strive to provide services and care under standardized nursing procedures. Per policy prior to initiating any nursing procedure wash hands and following the nursing procedure clean the equipment as appropriate and wash hands again. 555112 Page 31 of 32 555112 12/06/2021 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a record review of the facility's policy titled hand hygiene (9/1/2020), policy indicated the facility considers hand hygiene as the primary means to prevent the spread of infections. Hand hygiene meant cleaning hands by handwashing (washing hands with soap and water), antiseptic hand wash or antiseptic hand rub (alcohol-based hand rub [ABHR])). Per policy, facility staff, healthcare personnel (HCP), residents, visitors, and volunteers must perform HH to prevent the transmission healthcare associated infections (infection acquired in the healthcare facility [HAI]). Policy further indicated the following situations required appropriate hand hygiene: immediately upon entering and exiting a resident room and after contact with non-intact skin, wound drainage, and soiled dressing. During a review of the facility's mitigation plan 2020, mitigation plan indicated HCP and all other staff members should perform HH before and after ALL resident encounters including in multi-occupancy rooms as per World Health Organization's (WHO) 5 Moments of Hand hygiene (global campaign to promote HH practices to save lives). Per mitigation plan, all staff, residents, and visitors should perform HH frequently including every time they enter and exit the facility, resident rooms, and common areas; before and after eating; after using the restroom. WHO's five (5) moments of hand hygiene recommend HCP to clean their hands: 1. before touching a patient, 2. before clean/ aseptic procedures, 3. after body fluid exposure/ risk, 4. after touching the patient, and 5. after touching patient surroundings. 555112 Page 32 of 32