Health inspection·February 28, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure staff were knowledgeable of the facility's process on how to handle unlabeled resident clothes found in the laundry area and failed to complete a resident belonging list upon readmission for one of seven sampled resident's (Resident 1), to protect the resident's property from loss or theft. This failure had the potential to violate Resident 1's right to a safe and home like environment. Findings: During a review of Resident 1's admission Record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of encephalopathy (a group of conditions that cause brain dysfunction such as confusion and memory loss), after being sent out to a general acute care hospital on 7/16/2024. During a review of Resident 1's Minimum Data Set ([MDS], a federally mandated resident assessment tool) dated 2/14/2025, the MDS indicated Resident 1 had moderate (average) cognitive impairment (problems with the ability to think and solve problems) and was dependent (helper does all the effort) to perform Activities of Daily Living (ADL) such as showering/bathing self and performing toileting hygiene. During an interview on 2/27/2025 at 1:47 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated when a resident has clothes that are dirty during room transfers, resident's clothes should be given to the laundry and returned to the resident once clean. During an interview on 2/27/2025 at 2:53 p.m. with the Laundry Services (LS) 1, LS 1 stated any unlabeled resident clothes were placed directly to the facility's donation box. During an interview on 2/28/2025 at 9:33 a.m. with LS 2, LS 2 stated that when resident clothes not labeled with names, the clothes should be kept in the laundry room and should not be placed in the donation box. During a concurrent interview and record review on 2/28/2025 at 10:46 a.m. with the Medical Records (MR), Resident 1 belongings for 7/19/2024 was to be reviewed. The MR stated Resident 1 did not have a belongings list created upon readmission on [DATE]. During an interview on 2/27/2025 at 12:49 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 Page 1 of 4 555348 555348 02/28/2025 Granada Post Acute 3565 E Imperial Hwy Lynwood, CA 90262

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated when residents are being moved to a different room, the residents' belonging lists should be checked to ensure their belongings go with them. During an interview on 2/28/2025 at 3:18 p.m. with Director of Nursing (DON), the DON stated that laundry staff are to keep unlabeled resident's clothes in a designated area and to refer and compare these unlabeled clothing to residents' belongings list should resident report clothes missing. The DON also stated that upon admission an inventory list should be created for each resident. During a review facility's policy and procedure (P&P) titled, Theft and Loss Program, dated 9/2016, the P&P indicated, upon admission, an inventory should be made of all the resident's property brought into the facility. During a review of facility's P&P titled, Admitting the Resident: Role of the Nursing Assistant, undated, the P&P indicated inventorying resident belongings should include all clothing, equipment, and valuables by providing quantity and description of each item. 555348 Page 2 of 4 555348 02/28/2025 Granada Post Acute 3565 E Imperial Hwy Lynwood, CA 90262

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 implement its policy and procedures (P&P) titled, Comprehensive Care Planning, and Falls by a Resident, for one of seven residents (Resident 2) who had a fall on 2/19/2025, by failing to: 1. Conduct an Interdisciplinary Team ([IDT] group of healthcare professionals, including resident/ resident representative, working together to provide residents with needed care) meeting with Resident 2 and the family representative, to discuss and revise (change) the plan of care after Resident 2's fall on 2/19/2025. 2. Reassess and revise care plan interventions to ensure Resident 2's safety and to prevent recurrent fall. These failures placed Resident 2 at risk for recurrent falls and injuries. Findings: During a review of Resident 2's admission Record, the admission Record indicated, Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included polyneuropathy (a condition where multiple nerves in the body come damaged or dysfunctional) and aftercare following joint replacement surgery (a procedure that replaces a damaged joint with an artificial joint). During a review of Resident 2's Minimum Data Set ([MDS], a federally mandated resident assessment tool) dated, 2/13/2025, the MDS indicated Resident 2 was cognitively intact (having the ability to think, remember, and solve problems). The MDS indicated Resident 2 required partial/moderate assistance (helper does less than half the effort) to perform Activities of Daily Living (ADL) such as oral hygiene, showering/bathing self, and to toileting hygiene. During a review of Resident 2's progress notes dated 2/19/2025, Resident 2 was transferred out to the hospital after suffering an unwitnessed fall. During a review of Resident 2's care plan titled, 2/19/2025 acute or suspected fall, resident attempted to reach for paper on her table, the goal indicated injury will heal without signs and symptoms of infection/ complication in 14 days. The care plan did not indicate any safety interventions or any updated interventions for Resident 2's actual fall on 2/19/2025. During a concurrent interview and record review on 2/28/2025 at 1:15 p.m. with Registered Nurse (RN) 1, Resident 2's care plan titled 2/19/2025 acute or suspected fall, resident attempted to reach for paper on her table, was reviewed. RN 1 stated a care plan should be updated if there was a change of condition. RN 1 stated, a new care plan should have been made after Resident 2 suffered a fall to ensure that measures were in place to prevent furtherfalls that could lead to a bigger problem. During an interview on 2/28/2025 at 3:18 p.m. with the Director of Nursing (DON), the DON stated any resident who [NAME] fall required the IDT to meet, including the resident and family, to ensure plans and measures are in place to prevent any future falls. 555348 Page 3 of 4 555348 02/28/2025 Granada Post Acute 3565 E Imperial Hwy Lynwood, CA 90262

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review on 2/28/2025 at 3:47 p.m. with the DON, Resident 2's Change of Condition dated, 2/19/2025 and IDT meeting were reviewed. The DON stated that after Resident 2 fell on 2/19/2025, the care plan did not include intervention like the use of a reacher (a handheld mechanical tool used to increase the range of a person's reach and grasp when grabbing objects)to help Resident 2. The DON stated there was no documentation to support that an IDT meeting, including the resident and/or family representative was conducted after the Resident 2's fall on 2/19/2025. During a concurrent interview and record review on 3/4/2025 at 11:40 a.m. Resident 2's care plan titled, At risk for falls, dated 1/16/2025 was reviewed. The DON stated the intervention to provide reacher to Resident 2 to be able to reach items, should have been created and initiated on 2/19/2025 after Resident 2's first fall, and not on 2/28/2025. During a review of facility's P&P titled, Comprehensive Care Planning, dated 8/2015, the P&P indicated that a comprehensive care plan should be developed for each resident. The P&P indicated, care plan must be reviewed and revised periodically, at least quarterly, and on an ongoing basis to reflect changes in the resident and the services provided must be consistent with each resident's written plan. The P&P indicated, the MDS coordinator and/or Social Service staff should notify the resident, family and/or responsible party, and other interested parties designated by the resident, of the date and time of the scheduled care plan conference. The P&P indicated, to the extent possible, the resident, the resident's family and/or responsible party should participate in the development of the plan of care. During a review of facility's P&P titled, Falls by a Resident, dated, 7/2017, the P&P indicated after factors that contributed to the fall were identified, an update to an existing care plan should be generated. During a review of facility's P&P titled, Policy for the Interdisciplinary Team, dated 8/16, the P&P indicated that the Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. The P&P indicated, the resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development and revisions to the resident's care plan. 555348 Page 4 of 4