Health inspection·March 7, 2024

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident's responsible parties (RP) were informed of the utilization of bedrails and informed consent was given for two of 24 sampled residents (Resident 32 and Resident 66) by failing to: Residents Affected - Few These deficient practices did not allow the Resident 32 and Resident 66's RP's the right to be fully informed in advance of the bedrails. Findings: a. During a review of Resident 32's admission Record, the admission record indicated Resident 32 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including heart failure (progressive heart disease that affects pumping action of the heart muscles) and hemiplegia (weakness, stiffness, and lack of control in one side of the body). During a review of Resident 32's History and Physical (H&P) dated 3/7/2024, the H&P indicated Resident 32 could make needs known but could not make medical decisions. During a review of Resident 32's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/30/2023, the MDS indicated Resident 32's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was intact. The MDS indicated Resident 32 required substantial/maximal assistance (helper does more than half the effort) from staff for oral hygiene and required partial/moderate assistance (helper does less than half the effort) for eating. The MDS indicated Resident 32 was dependent on staff to roll from lying on back to left and right side and returning to lying on back on the bed. During a review of Resident 32's Consent for Bedside Rail Use, dated 2/29/2024, the consent indicated bilateral 1/3 bedside rails were ordered. The consent indicated the reason for use of bedrails was for mobility aid to improve functional ability in bed. The consent indicated Residents 32's RP (RP 2) gave telephone consent for the use of bedside rails. The consent indicated the nurse signed the consent indicating she verified the informed consent was given to RP 2. During an interview on 3/6/2024 at 10:34 a.m. with RP 2, in Resident 32's room, RP 2 stated she did not give consent for bedrails to be placed on Resident 32's bed. RP 2 stated she did not know the reason for the bedrails use. RP 2 stated the doctor nor the nursing staff called her to inform RP 2 the facility placed the bedrails on Resident 32's bed. During a concurrent interview and record review on 3/6/2024 at 10:51 a.m. with RP 2, the Consent Page 1 of 27 555112 555112 03/07/2024 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for Bed Rails, dated 2/29/2024 was reviewed. The consent indicated RP 2 was informed of the benefit and potential risks in using bedside rails. RP 2 reviewed the consent for bed rails and stated she was not aware of when they put the bedrails on Resident 32's bed and RP 2 stated on 2/29/2024 she did not speak to the staff or the doctor. b. During a review of Resident 66's admission Record, the admission record indicated Resident 66 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (disrupted blood supply and restricted oxygen supply to the brain) and hemiplegia. During a review of Resident 66's H&P dated 2/1/2024, the H&P indicated Resident 66 did not have the capacity to understand and make decisions. The H&P indicated Resident 66 was non-verbal, had left facial droop, and did not follow commands. During a review of Resident 66's MDS, dated [DATE], the MDS indicated Resident 66's cognitive skills for daily decision making was not intact. The MDS indicated Resident 66 had a history of atrial fibrillation (heart's upper chambers [atria] beat out of coordination with the lower chambers [ventricles]). During a review of Resident 66's Consent for Bedside Rail use, dated 2/3/2024, the consent indicated bilateral 1/3 bedside rails were ordered. The consent indicated the reason for use of bed rails was for mobility aid to improve functional ability in bed. The consent indicated Residents 66's RP (RP 1) gave telephone consent for the use of bedside rails. The consent indicated the nurse signed the consent indicating she verified the informed consent was given to RP 1. The consent indicated the doctor informed Resident 66's RP of the placement of bedrails. During an interview on 3/4/2024 at 2:38 p.m. with RP 1, in Resident 66's room, RP 1 stated he was not informed of the bedrails. RP 1 stated he did not give his consent to place the bedrails on Resident 66's bed. RP 1 stated he did not know the purpose for the bedrails and thought all residents had the utilization of bedrails. RP 1 stated nursing staff and the doctor did not inform him or ask for his consent for putting the bedrails on Resident 66's bed. During an interview on 3/8/2024 at 11:22 a.m. with Registered Nurse (RN) 1, RN 1 stated a nurse's signature on an informed consent indicated the nurse was present when the doctor explained the risks and benefits to the resident's RP and the RP's consent. RN 1 stated if her signature was on the informed consent, it meant she verified with the resident's RPs by being present when the doctor informed the RP of the bedrails. RN 1 stated a consent without a doctor's signature was an incomplete informed consent because the doctor's signature confirmed that the order was in place and confirmed that information was given to the RP. RN 1 stated that an informed consent without a doctors or nurses signature was an incomplete informed consent. RN 1 stated a nurse should have a complete consent for bed rails before placing bedrails on the bed. During an interview on 3/8/2024 at 11:56 a.m. with RN 1, RN 1 stated she actually did not talk to the RP before the bed rails were placed on the bed. RN 1 stated she was supposed to verify with the RP if they were informed about the bedrails and she did not. RN 1 stated the bedrails were placed on Resident 66's bed without RP 1's consent. During a review of the facility's Policy and Procedure (P&P) titled Informed Consent, dated 12/21/2023, the P&P indicated it was the practitioner responsibility to obtain informed consent for psychoactive medications physical restraints and medical devices. The P&P indicated verification of 555112 Page 2 of 27 555112 03/07/2024 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0552 Level of Harm - Minimal harm or potential for actual harm informed consent must be done before administering the first dose or first increased dose of psychoactive medications, applying physical restraints or medical devices, the licensed nurse will confirm that the healthcare practitioner obtained informed consent and will document the verification in resident's medical record. Residents Affected - Few 555112 Page 3 of 27 555112 03/07/2024 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, interview, and record review, the facility failed to report a change in condition of a resident's refusal of monthly weights to the physician for one out of three residents (Resident 6). Residents Affected - Few This deficient practice had the potential for Resident 6 to have continued weight loss without facility awareness and intervention. Findings: During a review of Resident 6's admission Record, the record indicated the facility originally admitted Resident 6 on 3/6/2023, and readmitted Resident 6 on 8/14/2023. Resident 6's admitting diagnoses included adult failure to thrive (a syndrome of weight loss, decreased appetite, and poor nutrition), signs and symptoms concerning food and fluid intake, dysphagia (difficulty swallowing), dementia (the loss of cognitive functioning such as thinking, remembering, and reasoning interfering with daily life and activities), abnormality of albumin (a protein necessary in the blood that keeps fluid from leaking into tissues), and depression. During a review of Resident 6's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 12/13/2023, the MDS indicated Resident 6 was severely cognitively impaired (ability to think and reason). The MDS indicated Resident 6 was required substantial/maximal assistance (helper does more than half the effort) with eating. During a review of Resident 6's current physician orders, dated 8/14/2024, the orders indicated Resident 6 was to receive monthly weights for monitoring. During a review of Resident 6's care plan titled, Nutritional Status, dated 8/14/2023, the Nutritional Status care plan indicated Resident 6 was at risk for weight loss related to failure to thrive, poor intake of food, depression, and low albumin. The Nutritional Status care plan further indicated to monitor Resident 6's monthly weights. The Nutritional Status care plan did not indicate any update regarding Resident 6's refusal to be weighed on 2/5/2024. During a review of Resident 6's monthly weights, dated 8/2023 through 3/2024, the monthly weights indicated Resident 6 was admitted with a weight of 121 pounds and has trended down to 107 pounds on 3/2/2024. The monthly weights further indicated Resident 6 refused to be weighed 2/2024. During an observation on 3/4/2024, at 9:05 a.m., Resident 6 was observed asleep in bed, with a thin appearance. During an observation and concurrent interview on 3/4/2024, at 1 p.m., Resident 6 was observed to have eaten 25% of her lunch. Resident 6 stated she was no longer hungry but to leave the tray so she could try to eat more. During an interview on 3/4/2024, at 1:24 p.m., with Restorative Nursing Assistant (RNA) 1, RNA 1 stated Resident 6 refused to be weighed on 2/5/2024. RNA 1 stated she tried to weigh Resident 6 on two more occasions but Resident 6 still refused. RNA 1 did not know the dates of the other two attempts, but stated she informed Registered Nurse (RN) 1. 555112 Page 4 of 27 555112 03/07/2024 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 Residents Affected - Few During an interview on 3/4/2024, at 1:35 p.m., with RN 1, RN 1 stated RNA 1 attempted to weigh Resident 6 three times and reported Resident 6's refusal to her. RN 1 stated she notified the physician and registered dietitian (RD, health professional who has special training in diet and nutrition) but did not remember the date. RN 1 stated she did not document it but should have. During a review of the facility policy and procedure (P&P) titled, Change of Condition, dated 8/2017, the P&P indicated: a. A licensed nurse will notify the physician of any acute medical changes or any sudden or serious change in condition manifested by a marked change in physical, mental, and psychosocial status. b. Communication would document using the Situation, Background, Assessment, and Recommendation ([SBAR] a structured communication framework that can help teams share information about the condition of a patient or team member or about another issue your team needs to address) tool. c. Except emergencies, the physician will be notified of the change within twenty-four (24) hours. d. The change of condition will be developed in the care plan. 555112 Page 5 of 27 555112 03/07/2024 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 - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement the person-centered care plan's (document that helps nurses and other team care members organize aspect of resident care) interventions for one of six sampled residents (Resident 39) when Certified Nursing Assistant (CNA) 1 only wore a gown when providing feeding assistance to Resident 39, who was on Enhanced Standard Precautions (ESP, infection control intervention using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug resistant organisms [MDRO]). This deficient practice had the potential to result in Resident 39 contracting an MDRO and potentially spreading the MDRO to other residents in the facility. Findings: During a review of Resident 39's admission Record (Face Sheet), the admission Record indicated Resident 39 was admitted to the facility on [DATE] with diagnoses that included but not limited to heart failure (a chronic condition in which the heart does not provide adequate blood flow to meet the body's needs), benign prostatic hyperplasia (BPH, an age-associated prostate gland enlargement that can cause urination difficulty), and cirrhosis of the liver (chronic liver damage from a variety of causes leading to scarring and liver failure). During a review of Resident 39's Minimum Data Set (MDS, a standardized screening and assessment tool), dated 12/21/2023, the MDS indicated Resident 39 was able to understand and be understood by others. The MDS indicated Resident 39's cognition (process of thinking) was severely impaired. The MDS indicated Resident 39 was dependent on staff for eating, toileting, and bathing. The MDS indicated Resident 39 had an indwelling urinary catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage). During a review of Resident 39's History and Physical Examination (H&P), dated 2/14/2024, the H&P indicated Resident 39 did not have the capacity to understand and make decisions. During a review of Resident 39's Order Summary Report, dated 3/1/2024, the Order Summary Report indicated Resident 39 was placed on enhanced precautions secondary to an indwelling urinary catheter use. During a review of Resident 39's Care Plan, dated 10/12/2023, the Care Plan indicated Resident was on ESP due to an indwelling urinary catheter and to use proper equipment when feeding the resident. During a review of the facility's Enhanced Standard Precautions sign, undated, the Sign indicated providers and staff must wear gloves and gown for high-contract resident care activities that include dressing, grooming, bathing, changing bed linens, and feeding. During an observation on 3/5/2024 at 12:25 p.m., in Resident 39's room, CNA 1 was providing feeding assistance to Resident 39. CNA 1 sat in a chair next to Resident 39's bed, CNA 1 wore a gown and was not wearing gloves. Outside of Resident 39's room, near the door frame, was the Enhanced Standard Precautions sign. 555112 Page 6 of 27 555112 03/07/2024 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 - Few During an interview on 3/5/2024 at 12:37 p.m., with the Infection Preventionist Nurse (IPN), the IPN stated Resident 39 was on ESP because he had an indwelling urinary catheter. The IPN stated having an indwelling urinary catheter placed Resident 39 at higher risk of contracting an MDRO and other infections. The IPN stated when a staff member provided any direct patient care to Resident 39, they had to wear a gown and gloves. The IPN stated wearing the appropriate personal protective equipment (PPE, protective garments or equipment such as gowns, gloves, masks, eye wear that is designed to offer protection from infection and disease) increased the protection for the resident and for the staff member. During an interview on 3/5/2024 at 12:56 p.m., with CNA 1, CNA 1 stated Resident 39 was on ESP, and she was required to wear a gown and gloves when she provided any care to him. CNA 1 stated Resident 39 required feeding assistance and she was supposed to wear a gown and gloves throughout the feeding session. CNA 1 stated she only wore a gown and she had forgotten to put on gloves prior to assisting Resident 39. During an interview on 3/6/2024 at 1:13 p.m., with the IPN, the IPN stated care plans dictated how the staff would care for the resident. The IPN stated in her area, care plans were developed for residents if they contracted an infection or if they required any precautions. The IPN stated the care plan would include the issue and the interventions to care for the resident such as monitoring, administering medications, or donning (put on) certain PPE. The IPN stated the care plan's interventions were created specifically for the resident and the appropriate staff members need to implement those interventions when caring for the resident. The IPN stated she expected all staff members to implement Resident 39's interventions for wearing the appropriate PPE when providing care to prevent any infection that could be harmful to the resident. The IPN stated if the care plan interventions were not followed, that put Resident 39 at risk for infection could possibly spread to other residents and staff. During an interview on 3/6/2024 at 2:45 p.m., with the Minimum Data Set Nurse (MDSN), the MDSN stated everyone had to do their part in implementing the residents' care plan interventions. The MDSN stated Resident 39 was on ESP because he was at higher risk for infection. The MDSN stated the care plan interventions indicated all staff members needed to use the proper equipment when providing care and all staff members needed to comply. The MDSN stated that intervention was in place to protect the resident, other residents, and the staff. During an interview on 3/6/2024 at 2:58 p.m., with Registered Nurse (RN) 1, RN 1 stated all staff members implement the interventions in the care plan to reach the resident's care goals. RN 1 stated care plan interventions regarding precautions for the resident should be followed. RN 1 stated residents on ESP were at higher risk for contracting an infection and implementing the interventions for PPE was for prevention. RN 1 stated the expectation of all staff when caring for a resident on ESP was to don a gown and gloves. RN 1 stated if a staff member did not don gown and gloves while providing care, they were putting the resident at risk for infection. During an interview on 3/7/2024 at 2:54 p.m., with the Director of Nursing (DON), the DON stated the purpose of a care plan was to guide the staff on how they would care for the resident based on the interventions created. The DON stated all staff members, if applicable, were expected to implement the interventions for the residents. The DON stated the interventions were based on the resident's condition, on how to treat a certain condition or to prevent any negative outcome. The DON stated Resident 39's care plan's interventions indicated to use proper equipment when providing care for the resident and she expected all staff members to follow those interventions. The DON stated following 555112 Page 7 of 27 555112 03/07/2024 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 - Few the interventions were important because they were put in place to lessen the risk of Resident 39 contracting an infection. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, revised 11/2018, the P&P indicated, It is the policy of this facility to provide person-centered, comprehensive, and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being. During a review of the facility's P&P titled, Enhanced Standard Precautions, revised 8/2019, the P&P indicated, The facility will reduce the potential for transmissions of pathogens including MDROs and viruses though the use of enhanced standard and transmission-based precautions. 555112 Page 8 of 27 555112 03/07/2024 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise the person-centered care plan (document that helps nurses and other team care members organize aspect of resident care) for one of six sampled residents (Resident 59) who had nonstop bleeding of their arteriovenous shunt (AVS, a connection between an artery and vein that is a commonly used access site in patients receiving regular hemodialysis [a process of filtering the blood of a person whose kidneys are not working normally]) and was sent to the general acute care hospital (GACH). This deficient practice had the potential to result in Resident 59's needs not being met due to staff being unaware on how to care for Resident 59's bleeding AVS. Findings: During a review of Resident 59's admission Record (Face Sheet), the admission Record indicated Resident 59 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included but not limited to transient cerebral ischemic attack (neurological event due to a temporary lack of adequate blood and oxygen to the brain), end stage renal disease (ESRD, a stage where the kidneys can no longer support the body's needs for waste removal and fluid balance), and type 2 diabetes mellitus (condition that results in too much sugar circulating in the blood). During a review of Resident 59's Minimum Data Set (MDS, a standardized screening and assessment tool), dated 12/4/2023, the MDS indicated Resident 59 was able to understand and be understood by others. The MDS indicated Resident 59's cognition (process of thinking) was moderately impaired. The MDS indicated Resident 59 received dialysis while a resident at the facility. During a review of Resident 59's History and Physical Examination (H&P), dated 2/29/2024, the H&P indicated Resident 59 had the capacity to understand and make decisions. During a review of Resident 59's Order Summary Report, dated 2/20/2024, the Order Summary Report indicated Resident 59 was to receive dialysis on Tuesday, Thursday, and Saturday at the dialysis center. The Order Summary Report indicated if bleeding occurred at the AVS site any time after dialysis, apply pressure with clean gauze for five to ten minutes, repeat until bleeding stops, notify the physician if the intervention does not control the bleeding. During a review of Resident 59's Care Plan titled, Emergency Bleeding: Dialysis Access Site, dated 10/27/2023, the Care Plan indicated Resident 59 had the potential for unavoidable bleeding on the AVS site and central line (a soft plastic tube that can be used for hemodialysis that is placed through the skin and into a large vein) related to ESRD with hemodialysis. During a review of Resident 59's Progress Notes, dated 2/20/2024 and timed at 2:03 p.m., the Progress Note indicated Resident 59 returned to the facility from the dialysis center and the nurse noted there was bleeding from the AVS on Resident 59's left upper arm and was able to stop the bleeding after putting pressure on the site. During a review of Resident 59's Situation-Background-Assessment-Recommendation (SBAR) Communication Form, dated 2/20/2024, the SBAR indicated Resident 59 had non-stop bleeding of their AVS and was 555112 Page 9 of 27 555112 03/07/2024 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few transferred to the GACH. The SBAR indicated at 3:45 p.m., Resident 59's AVS dressing was saturated with blood and pressure was applied to the site and Resident 59's physician was notified and gave the order to transfer Resident 59 to the GACH. The SBAR indicated Resident 59 left the facility to the GACH at 3:55 p.m. During a concurrent interview and record review on 3/6/2024 at 10:28 a.m., with Licensed Vocational Nurse (LVN 1), Resident 59's Care Plan titled, Emergency Bleeding: Dialysis Access Site, dated 10/27/2023, was reviewed. The Care Plan did not notate any revisions made to the document. LVN 1 stated Resident 59 had a care plan regarding his risk for bleeding from his AVS, however, the care plan was not updated after he had the bleeding episode. LVN 1 stated residents' care plans were to be updated when a change of condition occurred. LVN 1 stated Resident 59's care plan should have been updated upon his transfer to the GACH and when he was readmitted to the facility. LVN 1 stated updating Resident 59's care plan was important to ensure he received the proper care and to ensure the staff were guided on how to care for Resident 59. During an interview on 3/6/2024 at 2:33 p.m., with the MDSN, the MDSN stated care plans were used as a guide on how to care for the residents based on the goals. The MDSN stated the staff were responsible to try to achieve the residents' goals and if they are unable to, the care plans were revised with new interventions. The MDSN stated when a resident's condition changes, the care plan had to be updated. The MDSN stated after Resident 59 had bleeding at this AVS, his care plan should have been updated on how to care for them during that specific situation. The MDSN stated Resident 59's care plan was based on his potential for bleeding, however, now that he had the specific problem of his AVS bleeding, the nurses now needed a guide on how to treat it. The MDSN stated care plans were utilized as a communication tool and notating the bleeding incident would allow for any future incidents to determine if there was a trend. The MDSN stated if Resident 59's AVS were to bleed again, the nurses may not be aware he had bled before and would not be treated appropriately. During an interview on 3/6/2024 at 2:50 p.m., with Registered Nurse (RN) 1, RN 1 stated care plans communicate the status of a resident and anything they were at risk for. RN 1 stated a resident's care plan had to be updated when they had any kind of change of condition for the staff to see if there was a better way to care for the resident. RN 1 stated the care plan's interventions may be revised if the previous interventions did not work. RN 1 stated Resident 59's care plan that indicated his risk for bleeding should have been updated to convey his bleeding episode. During an interview on 3/7/2024 at 3 p.m., with the Director of Nursing (DON), the DON stated care plans were utilized as a guide on how to care for the residents based on their condition. The DON stated the nurses were to follow the written interventions. The DON stated whenever a resident sustained a change in condition, their care plan should be revised. The DON stated Resident 59's potential for bleeding had become an actual condition that required interventions and monitoring. The DON stated care plans should mirror the resident's condition that include specific interventions on how to treat the condition and prevent further occurrence. The DON stated since Resident 59's care plan was not updated; he was at risk for recurrency of bleeding at this AVS because he was now at a higher risk for bleeding and the nurses would not have a guide on how to intervene if his AVS were to bleed again. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, revised 11/2028, the P&P indicated, Additional changes or updates to the resident's comprehensive care plan will be made based on the assessed needs of the resident . The comprehensive care plan will also be reviewed and revised at the following times: onset of new problems, change of 555112 Page 10 of 27 555112 03/07/2024 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0657 Level of Harm - Minimal harm or potential for actual harm condition, in preparation for discharge, to address changes in behavior and care, and other times as appropriate or necessary. During a review of the facility's P&P titled, Change of Condition, dated 8/2017, the P&P indicated when a resident has a change of condition, the care plan for the change of condition would be developed. Residents Affected - Few 555112 Page 11 of 27 555112 03/07/2024 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 Based on observation, interview, and record review, the facility failed to follow physician's orders for one out of three residents (Resident 19) by not getting Resident 19 out of bed. Residents Affected - Few This deficient practice had the potential to negatively affect Resident 19's psychosocial well-being due to lack of socialization and stimulation. Findings: During a review of Resident 19's admission Record, the record indicated the facility originally admitted Resident 19 on 12/17/2019, and readmitted Resident 19 on 1/11/2024. Resident 19's admitting diagnoses included chronic obstructive pulmonary disease ([COPD] a condition involving constriction of the airways and difficulty or discomfort in breathing), congested heart failure ([CHF] a condition where the heart does not adequately pump blood into the body), acute and chronic respiratory failure with hypoxia (a short-term higher in severity and long-term lesser in severity condition making it difficult to breath, accompanied with low oxygen in the blood), acute pulmonary edema (a short-term higher in severity fluid congestion of the lungs), functional quadriplegia (complete immobility due to severe disability), and a cerebral vascular accident (a brain clot or bleed causing lack of blood flow resulting in tissue death in the brain, also known as a stroke). During a review of Resident 19's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 11/30/2023, the MDS indicated Resident 19 was severely cognitively impaired (ability to think and reason), and Resident 19 was dependent (helper does all the effort and resident cannot contribute to any of the activity) requiring total assistance with eating, oral hygiene, toileting hygiene, showering/bathing, dressing, personal hygiene, moving, and repositioning. During a review of Resident 19's physician orders, dated 1/11/2024, the orders indicated Resident 19 was to receive continuous supplemental oxygen at a flow rate of two (2) L/min to maintain an oxygen saturation (measure of oxygen level in the blood) of 92 percent (%) or more for acute respiratory failure. During a review of Resident 19's physician orders, dated 1/12/2024, the orders indicated staff was to get Resident 19 out of bed and into the chair twice a week or as tolerated due to Resident 19's immobility, and for stimulation and socialization. During a review of Resident 19's care plan titled, Respiratory, dated 1/12/2024, the care plan indicated Resident 19 was at increased risk for respiratory distress due to history of COPD, pulmonary edema, CHF, and acute/chronic respiratory failure, to prevent complications which included abnormal lung sounds, shortness of breath, irregular respiration (breathing in an inconsistent and abnormal pattern), edema (fluid accumulation that can occur in the lungs, heart, or limbs), and activity intolerance. The care plan further indicated an approach to prevent said complications was to encourage Resident 19 to get out of bed and exercise as tolerated. During a review of Resident 19's care plan titled, Geri-chair (large padded chair with wheeled bases designed to assist individuals with limited mobility) Use, dated 1/16/2024, the care plan indicated Resident 19 was at increased risk for a lack of activities and environmental stimulation, and to get Resident 19 out of bed and into the Geri-chair as part of their approach in mitigating risk or preventing potential problems. 555112 Page 12 of 27 555112 03/07/2024 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0658 During a review of Resident 19's activities of daily living (ADL) flowsheet, dated between 1/12/2024 through 3/4/2024, the ADL flowsheet indicated: Level of Harm - Minimal harm or potential for actual harm a. In the month of January 2024, Resident 19 was not taken out of bed. Residents Affected - Few b. In the month of February 2024, Resident 19 was out of bed once on 2/1/2024. c. In the month of March 2024, Resident was not taken out of bed. During an observation on 3/4/2024, at 8:48 a.m., Resident 19 was observed asleep, lying on her back in bed, and was on 2L of oxygen via nasal cannula (a device that fits into the nostrils and connects to an oxygen tank with a tube). During an observation on 3/5/2024, at 1:06 p.m., Resident 19 had a moist, weak sounding, non-productive (unable to produce phlegm) cough. During an observation and concurrent interview on 3/6/2024, at 9:00 a.m., with Registered Nurse (RN) 1, Resident 19 had diminished (shallow breaths which does not properly exchange gas upon inhalation or exhalation) lungs with crackles (a sound observed by listening to the lungs which is indicative of fluid in the lungs) on the right middle lobe (one out of three portions of the right lung). RN 1 stated she had made rounds to ensure residents get out of bed to chair but did not have a system in place. RN 1 stated Resident 19 had not been taken out of bed to Geri-chair since 3/4/2024. RN 1 stated Resident 19 got out of bed last week but did not recall the date or days of the week. RN 1 stated there were no records to document getting residents out of bed. RN 1 stated Resident 19 had an order to get out of bed twice a week but did not have any set days. RN 1 stated getting Resident 19 out of bed would help her with socialization, stimulation, and help her lungs with breathing. RN 1 stated the charge nurses were responsible for assessing residents' lungs. During an interview on 3/6/2024, at 9:12 a.m., with Certified Nursing Assistant (CNA) 4, CNA 4 stated the last time she had gotten Resident 19 out of bed was 2 weeks ago. CNA 4 stated she did not know how many times a week Resident 19 needed to get out of bed but would get her out of bed if a licensed nurse had told her to. During an interview on 3/6/2024, at 9:22 a.m., with the Director of Staff Development (DSD), the DSD stated she oversaw the certified nursing assistants (CNAs) and monitored residents by making daily rounds to ensure residents were getting out of bed and being turned. The DSD stated she knew when and who needed to get out of bed and be turned but did not write it down. The DSD stated she was not sure if residents getting out of bed should be documented. The DSD stated if Resident 19 had an order to get out of bed staff should be following the orders. The DSD stated she does not know if Resident 19 had an order to get out of bed. The DSD stated getting Resident 19 out of bed would help her lungs and breathing. During an interview and concurrent record review on 3/6/2024, at 9:32 a.m., with the Director of Nursing (DON), the DON stated she did not know how CNAs knew when to get residents' out of bed, but she thinks its verbally discussed during the daily huddle between nurses when the nurses exchange resident information. The DON stated according to Resident 19's flow sheet, staff had not been getting Resident 19 out of bed as ordered, which would help with Resident 19's lungs by postural drainage (techniques that utilize positioning to help drain fluid from the lungs and heart). 555112 Page 13 of 27 555112 03/07/2024 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 staff failed to assist residents who were unable to carry out their activities of daily living (ADLs, self care activities performed daily such as grooming, personal hygiene, and dressing) for two out of 24 sampled residents (Resident 32 and Resident 43) by failing to: Residents Affected - Few 1. Ensure Resident 32's and Resident 43's teeth were routinely brushed. 2. Ensure Resident 32's and Resident 43's clothes were changed daily. 3. Ensure Resident 32 and Resident 43 got out of bed daily. These deficient practices had the potential to result in a negative impact on Residents 32's and Resident 43's quality of life and self- esteem. Findings: a. During a review of Resident 32's admission Record, the admission record indicated Resident 32 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including heart failure (progressive heart disease that affects pumping action of the heart muscles) and hemiplegia (weakness, stiffness, and lack of control in one side of the body). During a review of Resident 32's History and Physical (H&P) dated 3/7/2024, the H&P indicated Resident 32 could make needs known but could not make medical decisions. The H&P indicated Resident 32 had a diagnosis of depression (a common and serious mental illness that negatively affects how you feel, the way you think and how you act, causing feelings of sadness and/or a loss of interest in activities you once enjoyed). During a review of Resident 32's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/30/2023, the MDS indicated Resident 32's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was intact. The MDS indicated Resident 32 required substantial/maximal assistance (helper does more than half the effort) from staff for oral hygiene and required partial/moderate assistance (helper does less than half the effort) for eating. The MDS indicated Resident 32 was dependent on staff to roll from lying on back to left and right side and returning to lying on back on the bed. During a review of Resident 32's Care Plan for Activities of Daily Living (ADLs) related to left sided weakness, dated 4/22/2022, the care plan indicated Resident 32's goal was to maintain at current level of function. The staff's interventions indicated for staff to assist Resident 32 with dressing, with bathing/showering, and to assist with routine oral care in the morning, evening and nighttime. During a review of Resident 32's Care Plan for Self-care Deficit related to left sided weakness, dated 2/29/2024, the care plan indicated Resident 32's goal was to be clean, dry, and well-groomed daily for 90 days. The staff's interventions indicated to assist Resident 32's with ADLs as needed and to provide dental/oral care two times a day and as needed. 555112 Page 14 of 27 555112 03/07/2024 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0677 Level of Harm - Minimal harm or potential for actual harm During a review of Resident 32's Care Plan for Risk of Respiratory Distress related to congestive heart failure (CHF, a chronic condition in which the heart doesn't pump blood as well as it should), dated 2/29/2024, the care plan indicated Resident 32's goal was to be relieved of any respiratory distress for 90 days. The staff's interventions indicated to encourage Resident 32 to be out of bed and to assist Resident 32 with ADL's. Residents Affected - Few During a review of Resident 32's ADL flowsheet, dated 2/1/2024 - 2/23/2024, the ADL flowsheet indicated Resident 32 was taken out of bed and placed on her wheelchair on 2/11/2024 and 2/16/2024. b. During a review of Resident 43's admission Record, the admission record indicated Resident 43 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including kidney failure (occurs when kidneys suddenly become unable to filter waste products from the blood, kidneys lose their filtering ability, dangerous levels of wastes may accumulate, and blood's chemical makeup may get out of balance) and metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood). During a review of Resident 43's H&P dated 12/21/2023, the H&P indicated Resident 43 had the capacity to understand and make medical decisions. During a review of Resident 43's MDS, dated [DATE], the MDS indicated Resident 43's cognitive skills for daily decision making was intact. The MDS indicated Resident 43 required partial/moderate assistance for eating and oral hygiene. During a review of Resident 43's Care Plan for Risk of Self-care Deficit, dated 4/23/2022, the care plan indicated the goal was Resident 43 would participate in self-care activities. The staff's interventions indicated for staff to provide assistance with ADLs and to maintain a consistent schedule with daily routine. During a review of Resident 43's Care Plan for Self- care Deficit, dated 12/20/2023, the care plan indicated Resident 43's goal was to be clean and well-groomed daily for 90 days. The staff's interventions indicated to assist Resident 43 with ADLs as needed and to provide dental/oral care two times a day and as needed. During a review of Resident 43's ADL flowsheet, dated 2/1/2024 - 2/29/2024, the ADL flowsheet indicated Resident 43 was taken out of bed and placed on her wheelchair on 2/11/2024, 2/14/2024, 2/16/2024, 2/17/2024, and 2/28/2024. During an observation on 3/4/2024 at 10:39 a.m. in Resident 32's and Resident 43's room, observed Resident 32 and Resident 43 in bed. Resident 32 was in bed, asleep and wearing pajamas. Resident 43 was in bed, awake, and a wearing gown. During an observation on 3/5/2024 at 8:30 a.m. in Resident 32's and Resident 43's room, observed Resident 32 and Resident 43 in bed. Resident 32 was in bed, asleep and wearing pajamas. Resident 43 was in bed, awake, and a wearing gown. During an interview on 3/5/2024 at 8:32 a.m. with Resident 43, in Resident 43's room, the Resident 43 stated the last time staff took her out of bed was two weeks prior. Resident 43 stated she usually stayed in bed everyday and would like to get out of bed to attend activities. Resident 43 stated she did not know she had a choice of when to get out of bed. Resident 43 stated she was bored of 555112 Page 15 of 27 555112 03/07/2024 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0677 being in bed every day. Level of Harm - Minimal harm or potential for actual harm During an interview on 3/5/2024 at 8:56 a.m. with Resident 32, in Resident 32's room, Resident 32 stated she did not remember the last time she got out of bed. Resident 32 stated staff took her out of bed only for shower time. Residents Affected - Few During an interview on 3/6/2024 at 9:29 a.m. with Resident 32 and Certified Nursing Assistant (CNA) 2, in Resident 32's room, Resident 32 stated she had not brushed her teeth yet. Resident 32 stated she asked CNA 2 to help her brush her teeth and CNA 2 stated to wait to get her teeth brushed during shower time. CNA 2 stated staff occasionally offer to get Resident 32 out of bed. Resident 32 stated she got out of bed 2 two days prior because staff needed to change her bed linen. CNA 2 stated she would like to get Resident 32 out of bed more because she got bored being in bed all day. Resident 32 stated staff did not offer her to get out of bed on a daily basis and that caused her to feel sad and depressed. During an interview with Licensed Vocational Nurse (LVN) 2 on 3/6/2024 at 10:15 a.m., in Resident 32's and 43's room, LVN 2 stated residents should be dressed and asked to get out of bed every day. LVN 2 stated she did not know Resident 32 and Resident 43 wanted to get out of bed. LVN 2 stated she was not aware that the residents were not offered to get out of bed. LVN 2 stated it was important for residents to get out of bed often to prevent further depression and for their overall health. During an interview on 3/6/2024 at 10:47 a.m. with Resident 32's Responsible Party (RP) 2, in Resident 32's room, RP 2 stated her only concern was staff did not take Resident 32 out of bed. RP 2 stated it had been one month that Resident 32 had not gotten out of bed. RP 2 stated Resident 32 mentioned to her that the resident would like to attend activities but staff did not offer to get the resident out of bed to attend activities. RP 2 stated Resident 32 stated she felt isolated because she did not get out of her room and was bored. During an interview on 3/6/2024 11:08 a.m. with Resident 43, in Resident 43's room, Resident 43 stated staff did not offer to get out of bed. Resident 43 stated she wanted to attend activities but when she asked staff to take her, the staff told her activities were over. Resident 43 stated she was bored staying in bed all day, every day. Resident 43 stated her CNA did not offer to brush her teeth today (3/6/2024) or yesterday (3/5/2024). Resident 43 stated CNAs hardly ever offer to assist with brushing the resident's teeth. During an interview on 3/6/2024 at 3:11 p.m. with CNA 2, the CNA 2 stated oral care was part of morning care. CNA 2 stated all residents needed to get their teeth brushed in the morning. CNA 2 stated she assisted Resident 32 with brushing her teeth today (3/6/2024) during shower time. CNA 2 stated she did not brush Resident 43's teeth today (3/6/2024) because Resident 43 had not asked for help with brushing her teeth. CNA 2 stated she did not brush Resident 32's and Resident 43's teeth on 3/5/2024 because she was busy. CNA 2 stated she waited for residents to ask her for assistance in brushing their teeth. CNA 2 stated it was acceptable to brush residents' teeth after lunch or until after dinner. CNA 2 stated it was important to make sure residents brush their teeth daily for better hygiene and to prevent cavities. CNA 2 stated residents must be taken out of bed two times a week. CNA 2 stated she did not take Resident 32 and Resident 43 out of bed because the residents did not ask her to take them out of bed. CNA 2 stated she was supposed to offer Resident 32 and Resident 43 to get out of bed but she did not because she was busy. CNA 2 stated it was important to offer residents to get out of bed to avoid skin sores, alleviate back pain, and so they could attend activities. 555112 Page 16 of 27 555112 03/07/2024 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 3/8/2024 at 12:00 p.m. with Registered Nurse (RN) 1, RN 1 stated the CNAs were expected to brush residents' teeth every day. RN 1 stated the CNAs were expected to provide oral care in the morning. RN 1 stated residents must be offered to be taken out of bed two times a week. RN 1 stated she did not know the facility's policy about offering residents to get out of bed every day. During a review of the facility's Policy & Procedure (P&P) titled, Standards for Care Activities of Daily Living, dated 2/2017, the P&P indicated residents will be out of bed and dressed appropriately each day per the resident's choice. The P&P indicated CNAs would assist residents to keep clean, neat and well groomed. 555112 Page 17 of 27 555112 03/07/2024 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to prevent pressure ulcer (injury to the skin and underlying tissue resulting from prolonged pressure on the skin) development for one out of three residents (Resident 19) by not turning Resident 19 as needed. Residents Affected - Few This deficient practice resulted in Resident 19 developing a Stage II (partial thickness loss of the top layer of the skin presenting a shallow open ulcer with a red, pink wound bed) pressure ulcer, and had the potential to negatively affect Resident 19's skin by potentially becoming infected and spreading to the bone or blood stream. Findings: During a review of Resident 19's admission Record, the record indicated the facility originally admitted Resident 19 on 12/17/2019, and readmitted Resident 19 on 1/11/2024. Resident 19's admitting diagnoses included chronic obstructive pulmonary disease ([COPD] a condition involving constriction of the airways and difficulty or discomfort in breathing, which could cause a delay in wound healing due to lack of oxygen), congestive heart failure (a condition where the heart does not adequately pump blood into the body, which could cause a delay in wound healing due to blood not being able to circulate tissues normally), type 2 diabetes mellitus (a chronic condition where blood sugar is not regulated by the body normally, which could cause a delay in wound healing due to difficulty transporting blood nutrients to the tissues), and functional quadriplegia (complete immobility due to severe disability). During a review of Resident 19's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 11/30/2023, the MDS indicated Resident 19 was severely cognitively impaired (ability to think and reason). The MDS indicated Resident 19 was dependent (helper does all the effort and resident cannot contribute to any of the activity), requiring total assistance with eating, oral hygiene, toileting, hygiene, showering/bathing, dressing, personal hygiene, moving, and repositioning. The MDS further indicated that Resident 19 did not have any pressure ulcers on 11/30/2023, at the time of the MDS assessment. During a review of Resident 19's Physician Orders, dated 1/12/2024, the orders indicated Resident 19 was to receive a head-to-toe skin check on all areas of the skin every Friday. During a review of Resident 19's care plan titled Pressure Ulcer Risk, dated 1/12/2024, the care plan indicated Resident 19 was at increased risk for developing a pressure ulcer due to impaired mobility, inability to communicate, total dependence with all care, incontinence (inability to control) of bowel and bladder, history of pressure ulcers or non-healing wounds, bedfast (unable to get out of bed independently) status, and diagnosis of type 2 diabetes mellitus. The staff's interventions indicated to turn and reposition Resident 19. During an observation on 3/4/2024, at 8:48 a.m., Resident 19 was observed asleep, lying on her back in bed. During an observation on 3/4/2024, at 11:05 a.m., Resident 19 was observed awake, lying on her back. Resident 19 was not able to speak or move. During an observation on 3/4/2024, at 11:21 a.m., Resident 19 was observed asleep, lying on her 555112 Page 18 of 27 555112 03/07/2024 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0686 back. Level of Harm - Minimal harm or potential for actual harm During an observation on 3/4/2024, at 2:41 p.m., Resident 19 was observed awake, lying on her back. Resident 19 was not able to speak or move. Residents Affected - Few During an interview on 3/4/2024, at 2:49 p.m., with Certified Nursing Assistant (CNA 3), CNA 3 stated Resident 19 had redness on her tailbone but CNA 3 did not report it the redness to the licensed nurse. CNA 3 stated Resident 19 was last turned around 2:40 p.m. (on 3/4/2024) and Resident 19 was not on her back because a pillow was under Resident 19's left side. CNA 3 stated she did not know the last time she tuned Resident 19 prior to around 2:40 p.m. CNA 3 stated she tried her best to turn Resident 19 every 2 hours but did not know exactly when the resident was turned. CNA 3 stated she did not write down or keep a record of the turning times but looked at the clock to determine when to turn Resident 19. CNA 3 stated she first turned Resident 19 at 8:00 a.m., at the beginning of her shift. During an observation and concurrent interview on 3/4/2024, at 2:50 p.m., with Licensed Vocational Nurse (LVN) 3. LVN 3 stated Resident 19 had no pressure ulcers on her back. Resident 19 was observed supine (face up) with a pillow under her. Resident 19 was noted with partial thickness loss of the top layer of the skin presenting a shallow open ulcer with a red, pink wound bed on the left side of her sacral area (an area on the triangular bone on the lower back between the hip bones). LVN 3 stated she did not believe Resident 19 had a stage II pressure ulcer but a Stage I (non-blanchable [discoloration of the skin that does not turn white when pressed] redness) pressure ulcer because it was not shiny or moist. LVN 3 stated Resident 19 did not have any skin break down on her sacral area when she assessed Resident 19's skin on 3/1/2024 (Friday). During an interview on 3/6/2024, at 9:22 a.m., with the Director of Staff Development (DSD), the DSD stated she oversaw the CNAs who all monitored residents by making daily rounds to ensure residents were getting out of bed and being turned. The DSD stated she took a mental note of when and which resident needed to get up and be turned but did not write it down. The DSD stated she was not sure if residents getting out of bed or repositioning should be documented. During an interview on 3/6/2024, at 9:27 a.m., with the Infection Preventionist Nurse (IPN), the IPN stated the facility did not practice documenting the turning/repositioning of residents. During an interview on 3/6/2024, at 9:32 a.m., with the Director of Nursing (DON), the DON stated residents should be turned every 2 hours or as needed to prevent pressure ulcers. The DON stated the pressure ulcer on Resident 19's sacral area from 3/4/2024 was identified as a Stage II pressure ulcer. During a review of the facility policy and procedure (P&P) titled, Side Lying Position, dated 12/2017, the P&P indicated the purpose of the P&P was to relieve pressure points on the bedfast resident to prevent pressure ulcers. The P&P further indicated staff were supposed to: a. Provide proper side lying positioning for residents when necessary and as needed. b. Position the top leg by bending it at the knees and bringing it to a 90-degree angle. c. Keep the bottom of the leg straight or slightly bent. 555112 Page 19 of 27 555112 03/07/2024 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0686 d. Place a pillow between the resident's legs to support the weight of the leg and foot. Level of Harm - Minimal harm or potential for actual harm e. Place a pillow under the top arm. f. Be sure the bottom arm is placed in a comfortable position. Residents Affected - Few g. Document the positioning in the nurses' notes. 555112 Page 20 of 27 555112 03/07/2024 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 follow their oxygen administration policy for one resident out of 24 sampled residents (Resident 7) by not ensuring Resident 7's nasal cannula (a plastic medical device to provide supplemental oxygen therapy to people who have lower oxygen levels, device goes directly into the nostrils) was labeled. Residents Affected - Few This deficient practice increased the risk for Resident 7 to acquire a respiratory infection. Findings: During a review of Resident 7's admission Record, the admission record indicated Resident 7 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). During a review of Resident 7's History and Physical (H&P) dated 12/18/2023, the H&P indicated Resident 7 had the capacity to understand and make decisions. During a review of Resident 7's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 2/7/2024, the MDS indicated that Resident 7's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was intact. The MDS indicated Resident 7 required partial/moderate assistance (helper does less than half the effort) from staff for oral hygiene and lower body dressing, and required maximal assistance (helper does more than half the effort) for toileting hygiene, shower, and upper body dressing. The MDS indicated Resident 7 had a diagnosis of respiratory failure (a serious condition that makes it difficult to breathe on your own, lungs can't get enough oxygen into the blood). During a review of Resident 7's Order Summary Report, dated 12/16/2023, the order summary report indicated Resident 7 was to receive 2 liters per minute of oxygen to maintain oxygen above 92 percent (%). During an observation on 3/5/2024 at 9:19 a.m., in Resident 7's room, Resident 7 was observed sitting on her wheelchair receiving 2 liters of oxygen via nasal cannula (a plastic medical device to provide supplemental oxygen therapy to people who have lower oxygen levels, device goes directly into the nostrils) that was connected to a portable oxygen tank. The nasal cannula was not labeled with an open date. During an interview on 3/6/2024 at 1:14 p.m. with the Infection Preventionist Nurse (IPN), the IPN stated a humidifier (medical device that increases the humidity in the nostrils while using supplemental oxygen) and a nasal cannula were to labeled with an open date and were to be changed weekly. The IPN stated if the oxygen equipment was not dated, staff must remove the oxygen equipment immediately and replace them. The IPN stated oxygen equipment must be dated to prevent long term use of the equipment and to prevent respiratory infections. During an observation on 3/6/2024 at 12:53 p.m., in Resident 7's room, Resident 7 was observed sitting on her wheelchair eating lunch. Resident 7 was receiving oxygen through a portable oxygen tank attached to her wheelchair. Resident 7's nasal cannula was not dated. 555112 Page 21 of 27 555112 03/07/2024 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0695 Level of Harm - Minimal harm or potential for actual harm During an observation on 3/7/2024 at 2:48 p.m., in the hallway, Resident 7 was observed sitting on her wheelchair. Resident 7's nasal cannula was not dated. During an observation on 3/8/2024 at 3:11 p.m., in the hallway, Resident 7 was observed sitting on her wheelchair. Resident 7's nasal cannula was not dated. Residents Affected - Few 555112 Page 22 of 27 555112 03/07/2024 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure informed consents were signed by the physician prior to the use of administering two antipsychotic (used to treat various mental disorders) medications, and for the utilization of bedside rails for one out of 24 sampled residents (Resident 32). This deficient practice had the potential of delay of necessary services, poor continuity of care and poor follow-up on the resident's status. Findings: During a review of Resident 32's admission Record, the admission record indicated Resident 32 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including heart failure (progressive heart disease that affects pumping action of the heart muscles) and hemiplegia (weakness, stiffness, and lack of control in one side of the body). During a review of Resident 32's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/30/2023, the MDS indicated that Resident 32's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was intact. The MDS indicated Resident 32 required substantial/maximal assistance (helper does more than half the effort) from staff for oral hygiene, and required partial/moderate assistance (helper does less than half the effort) for eating. The MDS indicated Resident 32 was dependent on staff to roll from lying on back to left and right side and returning to lying on back on the bed. During a review of Resident 32's History and Physical (H&P) dated 3/7/2024, the H&P indicated Resident 32 was able to make needs known but could not make medical decisions. The H&P indicated Resident 32 had a diagnosis of depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act, causing feelings of sadness and/or a loss of interest in activities you once enjoyed). During a review of Resident 32's Consent for Psychoactive Medication, dated 2/29/2024, the consent indicated Resident 32 was to receive Xanax (medication used to treat anxiety [feeling of unease or excessive worry] and panic disorders) 0.5 milligrams (mg, unit of measurement) two times a day. The consent indicated Residents 32's Responsible Party (RP) 2 gave telephone consent for the use of the medication. The consent indicated the licensed nurse signed the consent indicating she verified that informed consent was given to RP 2. The consent was not signed by Resident 32's physician. During a review of Resident 32's Consent for Psychoactive Medication, dated 2/29/2024, the consent indicated Resident 32 was to receive Celexa (medication used to treat depression) 10 mg every day. The consent indicated Residents RP 2 gave telephone consent for the medication. The consent indicated the licensed nurse signed the consent indicating she verified that informed consent was given to RP 2. The consent was not signed by Resident 32's physician. During a review of Resident 32's Consent for Bedside Rail Use, dated 2/29/2024, the consent indicated bilateral 1/3 bedside rail were ordered. The consent indicated the reason for use of bed rails was for mobility aid to improve functional ability in bed. The consent indicated RP 2 gave telephone consent for the use of bedside rails. The consent indicated the licensed nurse signed the consent 555112 Page 23 of 27 555112 03/07/2024 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicating she verified that informed consent was given to RP 2. The consent was not signed by Resident 32's physician. During an interview on 3/8/2024 at 11:22 a.m. with Registered Nurse (RN) 1, RN 1 stated a nurse's signature indicated the nurse was present when the physician explained the risk and benefits to the responsible party and they were ok with it. RN 1 stated she verified with the resident 's RP by being present when the physician informed the responsible party. RN 1 stated a consent without a physician's signature was incomplete because the signature confirmed that the order was in place and confirmed that information was given to the RP. RN 1 stated a nurse was not allowed to administer medication without a complete informed consent. RN 1 stated a physician's signature stated he/she explained to the RP or resident of what medication was ordered. RN 1 stated a nurse should have a complete consent for bedside rails before use. During an interview on 3/8/2024 at 1:50 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated prior to administering an antipsychotic medication a nurse must check if there was a consent for that medication. LVN 2 stated that a nurse must check if the informed consent was complete, by checking if the resident/RP and physician signed the informed consent. LVN 2 stated it was not acceptable to give medication without a physician's signature. LVN 2 stated it was important to check the consent form for the physician's signature because the signature indicated the physician informed the resident/RP of the risks and benefits of the recommended treatment. During a review of the facility's Policy and Procedure (P&P) titled, Informed Consent, dated 12/21/2023, the P&P indicated it was the practitioner's responsibility to obtain informed consent for psychoactive (psychotropic) medications, physical restraints, and medical devices. The P&P indicated verification of informed consent must be done before administering the first dose or first increased dose of psychoactive medications, applying physical restraints, or medical devices. The P&P indicated the licensed nurse will confirm that the healthcare practitioner obtained informed consent and will document the verification in resident's medical record. 555112 Page 24 of 27 555112 03/07/2024 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to document medication administration of a Schedule II-controlled substance (drugs with accepted medical use but with a high abuse potential), Norco (medication used to treat moderate to severe pain), when administering medication to one out of three residents (Resident 9). This deficient practice had the potential for harm due to an inaccurate record of narcotic medication use, and the loss of accountability, which affected the controls against drug loss, diversion (transfer of a legally prescribed controlled substance from the individual for whom it was prescribed to another person for any illicit use), or theft. Findings: During a review of Resident 9's admission Record, the admission record indicated the facility admitted Resident 9 on 5/2/2023. Resident 9's admitting diagnoses included second degree burns (burns that only affect up to the second layer of the skin) of the right arm, and both legs. During a review of Resident 9's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 12/13/2023, the MDS indicated Resident 9 was cognitively intact (ability to think and reason). During a review of Resident 9's physician orders, dated 10/31/2027, the orders indicated Resident 9 was to receive one (1) tablet of Norco 5-325 milligrams ([mg] a unit of measurement) every four (4) hours as needed for severe pain. During a review of Resident 9's Medication Administration Record (MAR), dated 3/6/2024, the MAR indicated Resident 9 received Norco 5-325 mg on 3/6/2024, at 9:54 a.m. During a concurrent interview and record review on 3/6/2024, at 10:19 a.m., with the Infection Preventionist Nurse (IPN), Resident 9's Controlled Drug Inventory sheet, dated 2/25/2024 through 3/5/2024 was reviewed. The Controlled Drug Inventory sheet indicated Resident 9 had not received Norco 5-325 mg. The IPN stated administration of controlled substances such as Norco should have been documented in real time, and the count should have reflected the actual number of drugs left, as soon as it is taken out of the bingo card (bubble pack) container. During an interview on 3/7/2024, at 3:20 p.m., with the Director of Nursing (DON), the DON stated the moment a controlled substance was given the nurse should have documented it in the MAR, and the narcotic count sheet should have been updated right away to signify the medication was administered, and the count of the drugs that was left was correct to prevent drug diversion and medication errors. During a review of the facility policy and procedure (P&P) titled, Schedule II Controlled Substance Medication, dated 2023, the P&P indicated the purpose of the P&P is to provide guidelines on how controlled substances are handled at the facility per state and federal regulations. The P&P further indicated when controlled dangerous substances are administered the nurse must document the amount of medication remaining on the declining inventory sheet. 555112 Page 25 of 27 555112 03/07/2024 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 observation, interview, and record review, the facility failed to implement effective infection prevention measures for one of six sampled residents (Resident 39) when Certified Nursing Assistant (CNA) 1 only wore a gown when providing feeding assistance to Resident 39, who was on Enhanced Standard Precautions (ESP, infection control intervention using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug resistant organisms [MDRO]). Residents Affected - Few This deficient practice had the potential to result in Resident 39 contracting an MDRO and potentially spreading infection to other residents and staff. Findings: During a review of Resident 39's admission Record (Face Sheet), the admission Record indicated Resident 39 was admitted to the facility on [DATE] with diagnoses that included but not limited to heart failure (a chronic condition in which the heart does not provide adequate blood flow to meet the body's needs), benign prostatic hyperplasia (BPH, an age-associated prostate gland enlargement that can cause urination difficulty), and cirrhosis of the liver (chronic liver damage from a variety of causes leading to scarring and liver failure). During a review of Resident 39's Minimum Data Set (MDS, a standardized screening and assessment tool), dated 12/21/2023, the MDS indicated Resident 39 was able to understand and be understood by others. The MDS indicated Resident 39's cognition (process of thinking) was severely impaired. The MDS indicated Resident 39 was dependent on staff for eating, toileting, and bathing. The MDS indicated Resident 39 had an indwelling urinary catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage). During a review of Resident 39's History and Physical Examination (H&P), dated 2/14/2024, the H&P indicated Resident 39 did not have the capacity to understand and make decisions. During a review of Resident 39's Order Summary Report, dated 3/1/2024, the Order Summary Report indicated Resident 39 was placed on enhanced precautions secondary to an indwelling urinary catheter use. During a review of the facility's Enhanced Standard Precautions sign, undated, the Sign indicated providers and staff must wear gloves and gown for high-contract resident care activities that include dressing, grooming, bathing, changing bed linens, and feeding. During an observation on 3/5/2024 at 12:25 p.m., in Resident 39's room, CNA 1 was providing feeding assistance to Resident 39. CNA 1 sat in a chair next to Resident 39's bed, CNA 1 wore a gown and was not wearing gloves. Outside of Resident 39's room, near the door frame, was the Enhanced Standard Precautions sign. During an interview on 3/5/2024 at 12:37 p.m., with the Infection Preventionist Nurse (IPN), the IPN stated residents were placed on ESP if they were at a higher risk of infection due to the presence of invasive lines such as an indwelling urinary catheter or wounds. The IPN stated ESP was implemented for the safety of the resident because a staff member who provided care to them could be a carrier of an MDRO or other infections and could transmit to the resident. The IPN stated all residents 555112 Page 26 of 27 555112 03/07/2024 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 - Few who were on ESP had a sign outside their door that indicated the Six Moments for Enhanced Standard Precautions such as dressing, grooming, feeding, and wound care. The IPN stated Resident 39 was on ESP because he had an indwelling urinary catheter. The IPN stated having an indwelling urinary catheter placed Resident 39 at higher risk of contracting an MDRO and other infections. The IPN stated when a staff member provided any direct patient care to Resident 39, they had to wear a gown and gloves. The IPN stated CNA 1 was supposed to wear a gown and gloves when providing feeding assistance because bacteria and infection could be transmitted from CNA 1's hands to Resident 39's mouth. The IPN stated wearing the appropriate personal protective equipment (PPE, protective garments or equipment such as gowns, gloves, masks, eye wear that is designed to offer protection from infection and disease) increased the protection for the resident and for the staff member. During an interview on 3/5/2024 at 12:56 p.m., with CNA 1, CNA 1 stated Resident 39 was on ESP and she was required to wear a gown and gloves when she provided any care to him. CNA 1 stated Resident 39 required feeding assistance and she was supposed to wear a gown and gloves throughout the feeding session. CNA 1 stated she only wore a gown and she had forgotten to put on gloves prior to assisting Resident 39. During an interview on 3/6/2024 at 2:58 p.m., with Registered Nurse (RN) 1, RN 1 stated residents on ESP were at higher risk for contracting an infection and the expectation of all staff members who provide care to the resident was to don a gown and gloves. RN 1 stated if a staff member did not don gown and gloves while providing care, they were putting the resident at risk for infection. During an interview on 3/7/2024 at 2:35 p.m., with the Director of Nursing (DON), the DON stated ESP was put in place for residents who were at an increased risk of infection due to having an indwelling urinary catheter, open wounds, a history of MDRO, or other invasive lines. The DON stated ESP was a precaution that required anyone providing care to the resident to wear a gown and gloves. The DON stated wearing these items would protect the resident and the staff member from any transmission of bacteria and infection. The DON stated when the CNAs performed direct care to the resident such as repositioning, changing their diaper, feeding, dressing, and performing exercises, they were required to wear the gown and gloves. The DON stated wearing a gown and gloves while providing feeding assistance was essential because the hands were a way that bacteria transfers from one person to another. The DON stated staff members could be unaware of the bacteria they carried on their hands and if they were to provide feeding assistance to a resident on ESP and did not wear gloves, they could potentially transfer those bacteria to the resident. The DON stated then the bacteria could spread to other residents and other staff, causing infection. During a review of the facility's P&P titled, Enhanced Standard Precautions, revised 8/2019, the P&P indicated, The facility will reduce the potential for transmissions of pathogens including MDROs and viruses though the use of enhanced standard and transmission-based precautions. 555112 Page 27 of 27