Health inspection·October 18, 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 2-3-person assistance for activities of daily living for one of twenty-one residents (Resident 77). This deficient practice had the potential to affect the resident's self-worth and dignity, leading to feelings of misery and frustration. Findings: During a review of Resident 77's admission Record indicated the resident was admitted to the facility on [DATE]. Resident 77's diagnoses included morbid obesity (excessive body fat that increases the risk of health problems), bilateral (affecting both sides) primary osteoarthritis (disorder of the joints and bones that causes pain and stiffness) of knee, hemiplegia (paralyzed on one side of the body) following cerebral infarct (lack of blood supply to brain cells) affecting left non dominant side, hereditary (passing from parents to their children) and idiopathic (of unknown cause) neuropathy (disease causing numbness or weakness). During a review of Resident 77's History and Physical (H/P) record dated 5/27/2021, indicated the resident was alert, oriented, bedbound and had the capacity to understand and make decisions. During a review of Resident 77's Minimum Data Set ([MDS] a resident assessment and care screening tool) dated 12/31/2020, indicated the resident had no memory or decision-making problems, was able to make needs known and understand others. The MDS indicated the resident required extensive assist of two-plus-person physical assist for transfers and bed mobility. The MDS indicated the resident was always incontinent of urine and bowel. The MDS indicated the resident preferences for customary routine and activities, was very important for her to choose between a tub bath, shower, bed bath, or sponge bath. During a review of Resident 77's Care Plan titled Involved in Group Activities dated 6/1/2021 indicated the goals were for the resident to attend group activities of interest once weekly. The interventions indicated the resident would be offered assistance and escort to the activity functions. During a review of the resident's Care Plan titled Needs Assistance with ADLS (activities of daily living) dated 5/27/2021, indicated the resident's bed mobility was extensive and needed support of 2-3 staff to assist. The resident's toileting needs required total assistance with support of 2-3 staff for assistance. The care plan indicated for transfers; this resident required total assistance with the assistance of 2-3 staff members. The resident's goals were for resident to maintain a current Page 1 of 40 555368 555368 10/18/2021 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0550 level of ADL participation daily for 3 months. The approach for the plan was to assist resident as needed. Level of Harm - Minimal harm or potential for actual harm During a review of resident's Activity assessment dated [DATE] under Activity Preferences and Routines indicated, it was important for the resident to do things with groups of people and very important for the resident to shower. Residents Affected - Few During an interview with Resident 77 on 10/13/2021 at 10:07 a.m., Resident 77 stated, she doesn't always get two people to assist with activities. During an observation of Resident 77 on 10/14/2021 at 11:36 a.m., stated, she was waiting for assistance to get out of bed. The resident was observed being assisted out bed at 2:35 p.m. During an interview and concurrent observation Certified Nurse Assistant 5 (CNA) on 10/14/2021 at 2:29 p.m., was observed assisting Resident 77 without assistance. CNA 5 stated, it was difficult to assist the resident and as far as she knew when a resident was overweight and paralyzed, they were supposed to have two persons for assistance. CNA 5 was not told the resident required two persons for assistance out of bed. During an interview with Licensed Vocational Nurse (LVN 6) on 10/15/2021 at 9:19 a.m., LVN 6 stated he did not know where to find the information on how many persons were needed to assist this resident. During an interview with Licensed Vocational Nurse (LVN 6) on 10/15/2021 at 10:09 a.m., LVN 6 stated, he did not know the number of persons needed to assist the resident out of bed. During an interview with the Director of Staff Development (DSD) on 10/15/2021 at 11:18 a.m., the DSD stated he oversaw informing CNAs and LVNs each shift the number of persons for assistance of each resident needs. LVN 6 stated, he was not informed that morning how many staff persons the resident needed to get out of bed. During an interview with the Director of Nursing (DON) on 10/15/2021 at 11:42 a.m., DON stated staff should know how many persons assist is each resident, and they should know where to find this information. DON stated it is important to know this information to provide proper care with safety for staff and resident. During an interview with Certified Nurse Assistant 8 (CNA 8) on 10/18/2021 at 9:10 a.m., CNA 8 stated they usually get the resident out of bed 2 to 3 days a week. During a review of an undated policy and procedure titled Resident Rights indicated the resident had the right to self-determination through support of their choice, including the right to interact with members of the community and participate in community activities both inside and outside the facility. The resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident's choice. 555368 Page 2 of 40 555368 10/18/2021 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to obtain accurate information about the advanced directive (a legal document that states your wishes for medical care in an emergency and at end of life) status for four of five residents (Residents 33, and 41). For Residents 33, and 41, who were unable to make decisions, the facility documented their wishes without asking the residents or responsible parties. This deficient practice had the potential to violate Residents 29, 33, 41 and 66's, choices for medical care. Findings: During a review of the clinical records for Resident 33, the Face sheet indicated Resident 33 was originally admitted to the facility on [DATE], with diagnosis that included cerebral Infarction (damage to tissues in the brain due to a loss of oxygen), dysphasia (difficulty swallowing), and hemiplegia (total paralysis of one side of the body). During a review of the clinical records for Resident 33, The Minimum data Set (MDS - a comprehensive assessment and care screening tool), dated 8/2/2021, indicated Resident 33 had impaired decision making skills, responds adequately to simple and direct communication, only and was non-verbal. The MDS indicated Resident 33 made inaudible sounds and pointed at things to make his needs known. During a review of clinical records for Resident 33, the History and Physical examination dated 10/25/2020, indicated Resident 33 did not have the capacity to understand and make decisions. During a review of the clinical records for Resident 41, the Face sheet indicated Resident 41 was originally admitted on [DATE] and readmitted on [DATE]. Resident 41 diagnosis included epilepsy (a burst of uncontrolled electrical activity between brain cells (also called neurons or nerve cells) that causes temporary abnormalities in muscle tone or movements (stiffness, twitching or limpness), behaviors, sensations or states of awareness), schizoaffective disorder ( a chronic mental health condition characterized primarily by symptoms such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression), and hemiplegia (total or partial paralysis of one side of the body). During a review of the clinical records for Resident 41, the History and Physical Examination dated 12/12/20, indicated Resident 41 did not have the capacity to understand or make decisions. During a review of the clinical records for Resident 41, the Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 7/28/21, indicated Resident 41 usually made himself understood and was usually able to understand others. During a review of Resident 41's Physician's order for life sustaining treatement (POLST)dated 10/21/20, the POLST indicated Resident 41 Resident 41 did not have an advanced directive. During a concurrent interview and record review with Social Services Director (SSD), on 10/14/21, at 12:17 p.m., she stated every resident had the advanced directive acknowledgment form in their chart. SSD stated the advanced directive form had to meet the Physician Order for Life Sustaining 555368 Page 3 of 40 555368 10/18/2021 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Treatment [POLST] (a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency) form. SSD reviewed the form for Resident 33 and 41 which indicated Resident 33, made the decision to not formulate an advanced directive. SSD stated Resident 33 and 41 did not tell the SSD that they did not want to formulate an advanced directive. SSD stated Residents 33 was not competent to make a decision and should not have had the advanced directive acknowledgment form completed in the chart. SSD stated she made a mistake and completed Resident 33 acknowledgement form as she thought every resident needed to have the form completed. The facility's policy titled Advanced Directives revised 2021, indicated advanced directive would be respected in accordance with state law and facility policy. The policy indicated the SSD or designee would provide written information to the resident concerning their rights to formulate an advanced directive, enquire about the existence of any written advanced directive, and display the information in the medical records. The facility's Job Description titled Social Services Director revised 2021, indicated major duties and responsibilities included identifying the needs for medically-related social services and ensure these services were provided according to state and federal regulation; coordinate implementation and oversight of procedures to ensure social services actions and interactions were properly documented in each resident's medical record, and that legal, ethical, and professional standards are upheld. The job description indicated the Social Services Director would review the residents advanced directive with the resident/resident representative and ensure that staff was aware of the resident's code status and end of life wishes. 555368 Page 4 of 40 555368 10/18/2021 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. 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's nursing staff failed to identify, evaluate, and implement accident risks and hazard interventions for one (1) of four (4) sampled residents (Resident 51) by failing to: Residents Affected - Few 1. Assess and indicate appropriate use of side rails 2. Keep side rails lowered on the sides of the bed 3. Care plan the use of side rails These deficient practices resulted in the use of unnecessary restraints, absence of a continuous assessment, or monitoring and placed the resident at risk for serious physical injuries. Findings: During a review of Resident 51's admission Face Sheet, the Face Sheet indicated the resident was readmitted on [DATE] with an initial admission date of 10/01/2019. Resident 51's diagnoses included schizophrenia (mental disorder in which people interpret reality abnormally which may include delusions, hallucinations, disorganized speech, trouble with thinking and lack of motivation), major depressive disorder (impaired cognitive function and vegetative symptoms, such as disturbed sleep or appetite), unspecified dementia with behavioral disturbance (broad category of brain diseases that cause a long term and often gradual decrease in the ability to think and remember that is great enough to affect a person's daily functioning). During a review of Resident 51's History and Physical Examination ([H&P) record (formal and complete assessment of the patient and the problem) dated 8/10/2021, indicated that the resident was able to make needs known, but could not make medical decisions. During a review of Resident 51's Minimum Data Set [(MDS), a comprehensive assessment and care screening tool] dated 10/04/2021, the MDS indicated Resident 51 was receiving antipsychotic and antidepressant medications. The MDS also indicated that Resident 51 required limited assistance with two persons assistance for bed mobility and transfers; limited assistance with one person assistance for dressing, eating and total dependence with one person assistance for toilet use and personal hygiene. The MDS indicated Resident 51 did not have bed rails identified as physical restraints. During an observation on 10/13/2021 at 11:53 a.m., Resident 51 was laying on an air mattress, with the bed in a low position, both side rails were up, and a call light positioned in the resident's hand. During an observation on 10/14/21 at 11:19 a.m., Resident 51 was laying on an air mattress with the bed in a low position, call light within reach and both side rails were up. During an observation, interview and record review on 10/15/2021 at 1:32 p.m., the Director of Nursing (DON) stated that the facility has a no restraint policy and bed rails are only used for positioning or providing care, not for restraints. The DON walked over to Resident 51's room and observed the residents' side rails in the up position. The DON immediately called Certified Nurse Assistant 555368 Page 5 of 40 555368 10/18/2021 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (CAN 4) and instructed her to put the side rails in the down position. The DON stated, all employees are aware that the facility is restraint free and must place side rails back down after providing care for the residents. The DON also stated, Resident 51 does not need bed rails for positioning or as restraints because she does not even move or try to get out of bed. The DON stated, there was no documentation on device assessment or assessment for bed rail because there was no need for the resident. The DON stated, there was no care plan for bed rail use in the resident's medical chart because bed rails are not used for restraints or positioning for the resident. The DON stated, the bed rails should have been placed down after assisting, cleaning, or moving resident. The DON stated, they don't use side rails as restraints because of its safety issues like getting their limbs stuck in the rails or bumping their heads - which is why the facility is restraint free. During a review of the facility's policy and procedure titled Proper Use of Side Rails, revised 2021, indicated that the facility prohibits the use of side rails as a restraint. The policy and procedure indicated side rails are considered a restraint when they limit the resident's freedom of movement depending upon the individual's condition and circumstances. An assessment of the residents' symptoms and the reason for using side rails will be conducted prior to use, including their mental status and reason for use of the side rail, and will be documented in the residents' record. The physician will also review and order side rail usage as he deems necessary .The use of side rails as an assistive device will be addressed in the residents' care plan. During a review of the facility's policy and procedure titled Bed Safety, revised 2021, indicated that if side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the Attending Physician, and input from the resident and/or legal representative .Before using side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with side rails. When using side rails for any reason, the staff shall take measures to reduce related risks. 555368 Page 6 of 40 555368 10/18/2021 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0644 Level of Harm - Minimal harm or potential for actual harm Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: Residents Affected - Few 1. Incorporate the recommendations from the Preadmission Screening and Resident Review ([PASARR] a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) level II determination for one out of four residents (Resident 41) into the resident care and care plan 2. Accurately assess and complete the PASARR assessment for one out of four residents (Resident 33) These deficient practices resulted in Resident 41 not receiving the personalized care and services to improve his health outcome and had the potential to result in Resident 33 not receiving necessary care and services to improve his health Findings: a. During a concurrent interview and record review on 10/14/21, at 4:02 p.m., the Director of Nurses (DON) stated the PASRR recommendations for specialized services purpose was to ensure Resident 41 would get would receive the services and incorporate into his plan of care. The DON stated she did not know Resident 41 had recommendations for specialized services and the facility did not develop a care plan for Resident 41 specialized services. During a review of the clinical records for Resident 41, the Facesheet indicated Resident 41 was originally admitted on [DATE] and readmitted on [DATE]. Resident 41 diagnosis included epilepsy (a burst of uncontrolled electrical activity between brain cells (also called neurons or nerve cells) that causes temporary abnormalities in muscle tone or movements (stiffness, twitching or limpness), behaviors, sensations or states of awareness), schizoaffective disorder ( a chronic mental health condition characterized primarily by symptoms such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression), and hemiplegia (total or partial paralysis of one side of the body) During a review of the clinical records for Resident 41, the PASARR dated 10/21/20, indicated Resident 41 level I PASARR was positive. During a review of the clinical records for Resident 41, the Department of Health Care Services sent a letter for Resident 41 on 11/24/21, indicating the level II PASARR evaluation conducted on 11/24/20 made the determination for specialized services for resident 41. These services included psychotropic medication (any drug that affects brain activities associated with mental processes and behavior) end education monitor; mental health rehabilitation activities; activities of daily living training/reinforcement; supportive services, psychotherapy (treatment of mental disorder by psychological rather than medical means)/counseling; psychiatric consultation (a physician who specializes in the diagnoses and treatment of mental disorder); neuropsychology (a specialized field dedicated to understanding the relationships between brain and behavior) consultation; internal medicine (a clinical specialty devoted to the comprehensive care of adults) consultation; neurology ( a branch of medicine that deals with the anatomy, functions, and organic disorders of nerves and the nervous system) 555368 Page 7 of 40 555368 10/18/2021 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0644 Level of Harm - Minimal harm or potential for actual harm consultation; physical therapy; occupational therapy; social worker consultation; pain services consultation; continence retraining; and safety monitoring for falling and seizures During a review of the clinical records for Resident 41, the History and Physical Examination dated 12/12/20, indicated Resident 41 did not had the capacity to understand or make decisions. Residents Affected - Few During a review of the clinical records for Resident 41, the Resident Plan of Care Needs Assistance with Activities of daily living revised on 6/11/21, indicated Resident 41 required limited assistance with eating. The Plan of care approach included frequent assistance of needs During a review of the clinical records for Resident 41, the Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 7/28/21, indicated Resident 41 usually made himself understood and was usually able to understand others. The MDS indicated Resident 41 required extensive one person assistance with bed mobility, dressing, toilet use, and personal hygiene. The facility's policy titled Resident Assessment- Coordination with PASARR Program revised on 2021, indicated recommendations such as any specialized services, from PASARR level II determination and/or PASRR evaluation report would be incorporated into the resident's assessment, care planning, and transitions of care The facility's policy titled Comprehensive Care Plan revised 2021, indicated the facility would develop and implement a comprehensive person-centered care plan for each resident. The policy indicated the comprehensive care plan would describe at a minimum any specialized rehabilitation services the nursing facility would provide as a result of PASRR recommendations. b. During a review of Resident 33's admission record indicated Resident 33 was admitted to the facility on [DATE] with diagnoses including Schizoaffective Disorder (is a chronic mental health condition characterized primarily by symptoms of schizophrenia [a serious mental disorder in which people interpret reality abnormally], such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression) and Anxiety Disorder (a group of mental illnesses that cause constant and overwhelming worry and fear. A review of the Minimum data Set (MDS - a comprehensive assessment and care screening tool), dated 8/2/2021, indicated Resident 33 had impaired cognitive skills for daily decision making, and required extensive assistance from staff for personal hygiene and bathing. Resident 33 makes inaudible sounds and point at things to make needs known. During a review of Resident 33's PASARR Level l Screening dated 10/24/2020 indicated Level 1 was Negative. The form indicated only up to Section II was completed, six sections were not filled out. There are eight sections in form in total. The Physical Diagnosis written on the form at the time of admission to nursing facility did not indicate diagnosis of mental illness. The form did not indicate Schizoaffective Disorder diagnosis for Resident 33. During a concurrent interview with MDS on 10/14/2021, at 11:21 a.m., and record review of Resident 33's Physician Orders, MDS stated Resident 33 had a diagnosis for Schizoaffective Disorder from when he was admitted to the facility. The MDS agreed Resident 33 PASARR was inaccurate but the only way to get a PASARR screening was either admission, readmission, or a significant change. The MDS stated she was unsure unsure if Resident 33 needed another PASARR screening. 555368 Page 8 of 40 555368 10/18/2021 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with MDS on 10/15/2021 at 8:28 a.m., the MDS stated the PASARR was important to ensure the resident receive the right type of treatment. The MDS stated the PASARR form needed to be completed accurately and complete. The MDS stated the form completed for Resident 33 indicated he was a female although he was a male. During an interview with MDS on 10/15/21 at 10:56 a.m., the MDS stated the policy indicated Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. During a concurrent interview and record review with the DON on 10/15/2021 at 3:05 p.m., The DON stated the PASARR form for Resident 33 was incomplete and inaccurate. The DON stated Resident 33 on 10/23/20 was admitted to the facility with the diagnoses of Schizoaffective Disorder. DON stated, the previous PASARR Coordinator should have finished that. DON confirmed the PASARR assessment did not screen Resident 33 for the diagnosis of Alzheimer's disease and mental illness and they were left blank. During a review of the facility's Policy titled Resident Assessment- Coordination with PASARR Program revised 2021 under Policy Explanation and Compliance Guidelines; the policy indicated any resident who exhibited a newly evident or possible serious mental disorder, intellectual disability, or a related condition would be referred promptly to the state mental health or intellectual disability authority for a level II resident review. 555368 Page 9 of 40 555368 10/18/2021 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility's staff failed to follow through with the Preadmission Screening and Resident Review (PASSAR) recommendation to obtain a PASSAR level II evaluation for two (2) out of four (4) sampled residents (Resident 51 and 75). Residents Affected - Some This deficient practice had the potential to result in an inappropriate placement and unidentified specialized services for Resident 51 and 75. Findings: During a review of Resident 51's admission Face Sheet, the Face Sheet indicated Resident 51 was readmitted on [DATE] with an initial admission date on 10/01/2019. Resident 51's diagnoses included schizophrenia (mental disorder in which people interpret reality abnormally which may include delusions, hallucinations, disorganized speech, trouble with thinking and lack of motivation), major depressive disorder (impaired cognitive function and vegetative symptoms, such as disturbed sleep or appetite and unspecified dementia with behavioral disturbance (broad category of brain diseases that cause a long term and often gradual decrease in the ability to think and remember that is great enough to affect a person's daily functioning). During a review of Resident 51's History and Physical Examination ([H&P], formal and complete assessment of the resident and the problem) dated 8/10/2021, indicated that the resident is able to make needs known, but cannot make medical decisions. During a review of Resident 51's Minimum Data Set [(MDS), a comprehensive assessment and care screening tool] dated 10/04/2021, indicated Resident 51 was receiving antipsychotic and antidepressant medications. The MDS also indicated that Resident 51 requires limited assistance with two persons assist for bed mobility and transfers; limited assistance with one person assist for dressing and eating; and total dependence with one person assist for toilet use and personal hygiene. During a review of Resident 51's PASSAR completed on 08/05/2021, indicated the need for Level II PASSAR evaluation. During a review of Resident 51's clinical record, there was no documented evidence that a Level II PASSAR evaluation was done or any documentation that indicated the facility had followed up on obtaining a Level II PASSAR evaluation. During a review of Resident 75's admission Face Sheet, the Face Sheet indicated Resident 75 was readmitted on [DATE] with the initial admission date on 03/10/2017. Resident 75's diagnoses included schizophrenia (mental disorder in which people interpret reality abnormally which may include delusions, hallucinations, disorganized speech, trouble with thinking and lack of motivation), hypertension (elevated blood pressure), diabetes (abnormal blood sugar) and morbid obesity (excess body fat). During a review of Resident 75's History and Physical Examination ([H&P] record, formal and complete assessment of the resident and the problem) dated 8/15/2021, indicated the resident has fluctuating capacity to understand and make decisions. During a review of Resident 75's Minimum Data Set [(MDS), a comprehensive assessment and care screening tool] dated 09/02/2021, indicated Resident 75's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS also 555368 Page 10 of 40 555368 10/18/2021 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0645 indicated, Resident 75 was receiving antipsychotic medications. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 75's PASSAR completed on 08/16/2021, indicated the need for Level II PASSAR evaluation. Residents Affected - Some During a review of Resident 75's clinical record, there was no documented evidence that a Level II PASSAR evaluation was done or any documentation that indicated the facility had followed up on obtaining a Level II PASSAR evaluation. During an interview on 10/14/2021 at 3:35 p.m., with the Minimum Data Set Coordinator (MDS) stated, that she is responsible for Level I PASSAR submission. She stated, that if the PASSAR Level I is positive and need Level II PASSAR, the business office manager follows up. The MDS person stated, she does not follow up for Level II PASSAR evaluation. During an interview on 10/14/2021 at 3:57 p.m., the Business Office Manager (BOM) stated, she is not responsible for following up on PASSAR Level II evaluation. She stated, she does not deal with the MDS and is given the password for billing purposes only. During an interview and record review on 10/14/2021 at 4:02 p.m., the Director of Nursing (DON) stated that the MDS person is responsible for transmission of initial PASSAR Level I. She stated that if PASSAR Level I is positive and need PASSAR Level II evaluation, the MDS and DON are responsible to follow up with the Department of Health Care Services (DHCS) to make sure an evaluation was done, and recommendations carried out. The DON stated, that for Resident 75, DHCS contacted and informed her they will fax paperwork, but the fax was not received. The DON could not provide documentation of conversation and did not follow up on paperwork that was not received. The DON stated that they did not receive a call from DHCS regarding Resident 51 and no follow up was done to obtain a PASSAR Level II evaluation for this resident. The DON stated, they should have followed up, but they missed it. She stated, PASSAR Level II is important so DHCS can give recommendations specific to individual resident treatments and services needed. During a review of the facility's policy and procedure titled Resident Assessment - Coordination with PASARR Program, revised 2021, indicated the purpose is for the facility to coordinate assessment with the preadmission screening and resident review (PASARR) program under Medicaid to the maximum extent practicable to avoid duplicative testing and effort. The policy and procedure indicated that all individuals with mental disorder or intellectual disability who apply for admission to this facility will be screened in accordance with the State's Medicaid rules for screening .Recommendations, such as any specialized services, from a PASSAR level II determination and/or PASSAR evaluation report will be incorporated into the resident's assessment, care planning and transitions of care. 555368 Page 11 of 40 555368 10/18/2021 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to identify, evaluate, and implement accident risks and hazard interventions for one (1) of four (4) sampled residents (Resident 51) by failing to: 1. Assess and indicate appropriate use of side rails 2. Keep side rails lowered on the sides of the bed 3. To care plan the use of side rail These deficient practices resulted to unnecessary restraint, absence of continued assessment and monitoring and placed the resident for potential risk for serious physical injuries. Findings: During a review of Resident 51's admission Face Sheet, the Face Sheet indicated Resident 51 was readmitted on [DATE] with initial admission date on 10/01/2019. Resident 51's diagnoses included schizophrenia (mental disorder in which people interpret reality abnormally which may include delusions, hallucinations, disorganized speech, trouble with thinking and lack of motivation), major depressive disorder (impaired cognitive function and vegetative symptoms, such as disturbed sleep or appetite), unspecified dementia with behavioral disturbance (broad category of brain diseases that cause a long term and often gradual decrease in the ability to think and remember that is great enough to affect a person's daily functioning). During a review of Resident 51's History and Physical Examination ([H&P], formal and complete assessment of the patient and the problem), dated 8/10/2021, indicated that the resident was able to make needs known, but was unable to make medical decisions. During a review of Resident 51's Minimum Data Set (MDS) a comprehensive assessment and care screening tool dated 10/04/2021, indicated Resident 51 is receiving antipsychotic and antidepressant medications. The MDS also indicated, Resident 51 requires limited assistance with two persons assistance for bed mobility and transfer; limited assistance with one person assist for dressing and eating; and total dependence with one person assist for toilet use and personal hygiene. The MDS indicated, Resident 51 does not have physical restraints such as bed rail. During an observation on 10/13/2021 at 11:53 a.m., Resident 51 was laying on an air mattress, with the bed in a low position, both side rails up, with the call light in her hand. During an observation on 10/14/21 at 11:19 a.m., Resident 51 was laying on an air mattress, bed in low position, with the call light within reach and both side rails up. During an observation, interview, and record review on 10/15/2021 at 1:32 p.m., the Director of Nursing (DON) stated, the facility has a no restraint policy and bed rails are only used for positioning or providing care, not for restraint. The DON walked over to Resident 51's room and observed the residents' side rails up. The DON immediately called Certified Nurse Assistant (CNA 4) and instructed her to bring the side rails down. The DON stated, all employees are aware that the facility is 555368 Page 12 of 40 555368 10/18/2021 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few restraint free and must place side rails back down after providing care for the residents. The DON stated, Resident 51 does not need bed rails for positioning or as restraints because she does not even move or try to get out of bed. DON stated there is no documentation on device assessment or assessment for bed rail because there was no need for the resident. The DON stated, there is no care plan for bed rail use in resident medical chart because bed rail is not used for restraint or positioning for resident. She stated, the bed rails should have been placed down after assisting, cleaning, or moving resident. She stated they don't use side rails as restraints because of its safety issues like getting their limbs stuck in the rails or bumping their heads - which is why the facility is restraint free. During a review of the facility's policy and procedure (p/p) titled Proper Use of Side Rails, revised 2021, indicated that the facility prohibits the use of side rails as a restraint. P/p indicated side rails are considered a restraint when they limit the resident's freedom of movement depending upon the individual's condition and circumstances. An assessment of the residents' symptoms and the reason for using side rails will be conducted prior to use, including their mental status and reason for use of the side rail, and will be documented in the residents' record. The physician will also review and order side rail usage as he deems necessary .The use of side rails as an assistive device will be addressed in the residents' care plan. During a review of the facility's policy and procedure titled Bed Safety, revised 2021, indicated that if side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the Attending Physician, and input from the resident and/or legal representative .Before using side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with side rails. When using side rails for any reason, the staff shall take measures to reduce related risks. 555368 Page 13 of 40 555368 10/18/2021 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

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 interview, and record review, the facility failed to develop a person centered care plan for one of 21 residents (Resident 41). Resident 41 who needed assistance with positioning during meals. The deficient practice resulted in the staff not properly positioning Resident 41 during meals and had the potential to result in choking and/or death for Resident 41. Finding: During a review of the clinical records for Resident 41, the Facesheet indicated Resident 41 was originally admitted on [DATE] and readmitted on [DATE]. Resident 41 diagnosis included epilepsy (a burst of uncontrolled electrical activity between brain cells (also called neurons or nerve cells) that causes temporary abnormalities in muscle tone or movements (stiffness, twitching or limpness), behaviors, sensations or states of awareness), schizoaffective disorder ( a chronic mental health condition characterized primarily by symptoms such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression), and hemiplegia (total or partial paralysis of one side of the body) During a review of the clinical records for Resident 41, the History and Physical Examination dated 12/12/20, indicated Resident 41 did not had the capacity to understand or make decisions. During a review of the clinical records for Resident 41, the Resident Plan of Care for Needs Assistance with Activities of daily living revised on 6/11/21, indicated Resident 41 required limited assistance with eating. The Plan of care approach included to provide frequent assistance for Resident 41's needs During a review of the clinical records for Resident 41, the Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 7/28/21, indicated Resident 41 usually made himself understood and was usually able to understand others. The MDS indicated Resident 41 required extensive one person assistance with bed mobility, dressing, toilet use, and personal hygiene. During an observation on 10/13/21, at 12:50 p.m., certified nurse assistant (CNA. 6) brought the meal tray for Resident 41 who was lying in bed with the head of the bed at a 35 degree angle and his body appeared to have slid down on the bed. During a concurrent interview and observation on 10/14/21, at 8 a.m., LVN 1 stated Resident 41 was not properly positioned for his meal and needed to sit up on the bed. Resident 41 was obsereved with the head of the bed elevated at a 35-degree angle, and the meal tray was elevated. During a concurrent interview and record review on 10/14/21, at 8:22 a.m., the Director of Nurses (DON) stated Resident 41 should be properly positioned for his meal to prevent him from chocking. The DON reviewed Resident 41's care plans and stated the care plan indicated Resident 41 required limited assistance with his meal. The care plan did not address how to position Resident 41 for the meal. The DON stated Resident 41 should be sitting up in the bed, and the meal tray should be lower. The facility's undated policy titled Meal Supervision and Assistance, indicated the resident would be prepared for a well-balanced meal with adequate supervision and assistance to prevent accidents. 555368 Page 14 of 40 555368 10/18/2021 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The policy indicated the compliance guidelines included to review the resident's care plan and provide special needs of the resident. The facility's policy titled Comprehensive Care Plan revised 2021, indicated the facility would develop and implement a comprehensive person-centered care plan for each resident. The policy indicated the comprehensive care plan would describe at a minimum the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 555368 Page 15 of 40 555368 10/18/2021 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

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 facility failed to: Residents Affected - Some 1. Properly position one out of two residents (Resident 41) who needed assistance with positioning during meals. The deficient practices had the potential to result on chocking and death for resident 41. This deficient practice had the potential to result on a resident's accidental use of the medication, harm and hospitalization. Findings: During a review of the clinical records for Resident 41, the Facesheet indicated Resident 41 was originally admitted on [DATE] and readmitted on [DATE]. Resident 41 diagnosis included epilepsy (a burst of uncontrolled electrical activity between brain cells (also called neurons or nerve cells) that causes temporary abnormalities in muscle tone or movements (stiffness, twitching or limpness), behaviors, sensations or states of awareness), schizoaffective disorder (a chronic mental health condition characterized primarily by symptoms such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression), and hemiplegia (total or partial paralysis of one side of the body) During a review of the clinical records for Resident 41, the History and Physical Examination dated 12/12/20, indicated Resident 41 did not had the capacity to understand or make decisions. During a review of the clinical records for Resident 41, the Resident Plan of Care Needs Assistance with Activities of daily living revised on 6/11/21, indicated Resident 41 required limited assistance with eating. The Plan of care approach included frequent assistance of needs During a review of the clinical records for Resident 41, the Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 7/28/21, indicated Resident 41 usually made himself understood and was usually able to understand others. The MDS indicated Resident 41 required extensive one person assistance with bed mobility, dressing, toilet use, and personal hygiene. During an observation on 10/13/21, at 12:50 p.m., certified nurse assistant (CNA 6) brought the meal tray for Resident 41 who was lying in bed with the head of the bed at a 35 degree angle and his body appeared to have slid down on the bed. CNA 6 left the room and Resident 41 start to eat his meal. During an observation and concurrent interview on 10/13/21, at 12:54 p.m., License Vocational Nurse (LVN 7) stated he did not know the reason Resident 41 was not sitting up during his meal. LVN 7 stated Resident 41 should be sitting up during his meal positioned to prevent him from chocking which could lead to death. During an observation and concurrent interview on 10/13/21, at 12:59, CNA 6 stated Resident 41 was not properly positioned to eat his meal which could cause him to choke and die. CNA 6 stated she did not call someone to help her lift Resident 41 because by the time she thought about getting help 555368 Page 16 of 40 555368 10/18/2021 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0658 the surveyor was already there. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and observation on 10/14/21, at 8 a.m., LVN 1 stated Resident 41 was not properly positioned for his meal and needed to sit up on the bed. Resident 41 was observed with the head of the bed elevated at a 35-degree angle, and the meal tray was elevated. Residents Affected - Some During an concurrent observation and interview on 10/14/21, at 7:56 a.m., CNA 5 stated Resident 41 had a tendency to slide on the bed and he should have been sitting up straighter to eat his meal. CNA 5 stated she was going to lower the tray, but Resident 41 did not want her to lower the tray and she left the meal tray elevated. During an interview on 10/14/21, at 8:22 a.m., the Director of Nurses (DON) stated Resident 41 should be properly positioned for his meal to prevent him from chocking. The DON stated Resident 41 should be sitting up on the bed, and the meal tray should be lower. The DON stated she would in-service her CNAs to ensure they know how to properly position residents during mealtime. The facility's undated policy titled Meal Supervision and Assistance, indicated the resident would be prepared for a well-balanced meal with adequate supervision and assistance to prevent accidents. The policy indicated the compliance guidelines included review the resident's care plan and provide special needs of the resident; the resident's head and upper body should be positioned as upright as possible with the head slightly forward. If the resident's meal was served while he or she were on the bed use wedges and pillows to achieve a nearly upright position. The policy indicated not to serve the meal until the attendant was ready to assist the resident and dishes and silverware should be arranged so that resident could reach them easily. The facility's undated job description titled Certified Nursing Assistant indicated the CNAs are to assist residents with activities of daily living in accordance with the care plan and established policies and procedures. The job description indicated CNAs would also assist the residents with positioning and mealtimes, including set-up and clean up, meal tray delivery, and feeding assistance. 555368 Page 17 of 40 555368 10/18/2021 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on interview and record review, the facility failed to follow its own policy to ensure the 6 of 6 employees had the knowledge base, capability, and capacity to perform their duties by performing an Initial Skills Competency (measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) and Annual Skills Competency checklist as needed and at least annually that was a part of the employee file. This deficient practice had the potential for 89 of 89 residents who resided in the facility not being assisted, not receive medically related care and services, which could cause serious injury, harm, impairment, or death. Findings: a. During a concurrent interview and record review on 10/18/2021 at 12:10 p.m., with Director of Staff Development (DSD) an employee files for License Vocational Nurse (LVN 2), Infection Preventionist (IP), Certified Nurse Assistant CNA2, CNA7, CNA8, CNA10 were reviewed. There were no Skills Check list form found in the employees' files. DSD stated the employees should have an annual Skills Competency Check list on their file upon hire, annually, and as needed thereafter to ensure the staff were competent in performing their duties. DSD stated he was responsible for ensuring the employee files were complete, however there were no Skills checklist found on the employee's file. DSD stated the Director of Nursing was responsible for assessing LVN's skills competency and the DSD was responsible for checking CNAs competencies. DSD stated he completed employee skills check list but gave it back to the employees and did not keep a record because he just started working as DSD in March 2021 and was not aware that he should keep it on the employee file and will do the competency again. During an interview and concurrent record review of employee files with DON on 10/18/2021 at 12:19 p.m., DON stated the Skills competency check list should be in the employee file and if it was not there that means it was not done. DON stated she was responsible for doing the Skills competency for RN and LVN, the DSD does the Skills competency for CNA but stated that they were not able to do it. DON stated Skills Competency should be completed upon hire and annually to ensure the employees were competent and had the skills to perform their duty safely while caring for the residents. The DON stated the Skills Check list should be kept in the employee's file as a proof to show the competency of the staff. During a review of the facility's policy and procedure titled, Staffing dated revised October 2017, indicated the facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and facility assessment. During a review of the facility's policy and procedure titled, Competency Evaluation dated revised 2019, indicated it is the policy of this facility to evaluate each employee to assure appropriate competencies and skills for performing his or her job and to meet the needs of the facility residents. Initial competency is evaluated during the orientation process, an employee remains on orientation until all competencies are verified. Subsequent and/or annual competency is evaluated at a frequency determined by the facility assessment, evaluation of the training program, and or job performance evaluation. Checklist are used to document training and competency evaluations. Employee competency 555368 Page 18 of 40 555368 10/18/2021 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0726 forms are maintained in the Staff Development Coordinator's office for current training year, then forwarded to the Human Resources Director for placing into the employee's personnel file. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 555368 Page 19 of 40 555368 10/18/2021 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility's staff failed to: 1. Label with an open date as required by their respective manufacturer's specifications, four inhalation solution foil packs (a drug or combination of drugs in mist form intended to reach the lungs) for one out one medication storage and one out of three medication carts (medication cart 1) medication for Residents 52 and 203. 2. Discard expired medication, three inhalation solution boxes from one out of one medication storage and one out of three medication carts (medication cart 1) medication for Residents 52 and 203. 3. Properly stored drugs in one out of three medication carts (medication cart #2). Medication cart # 2 had a disinfectant wipe stored with residents' medication. These deficient practices increased the risk of Residents' 52 and 203 receiving expired or potentially toxic medications and could result in hospitalization or death. Findings: 1. During a review of Resident 52's admission Record indicated Resident 52 was admitted to the facility on [DATE]. Resident 52's diagnosis included chronic obstructive pulmonary disease (is a disease that causes blocked airflow from the lungs). During a review of Resident 52's Care Plan titled Potential for impaired breathing pattern, shortness of breath, congestion wheezing, and respiratory distress indicated the resident goals were for the resident to have optimal breathing patterns. The facility's plan was to administer a breathing treatment pro re nata (P.R.N.) when necessary) as ordered for shortness of breath. During a review of Resident 203's admission Record indicated the resident was admitted to the facility on [DATE]. Resident 203's diagnosis included acute respiratory failure unspecified with hypoxia and hypercapnia (when fluid builds up in the air sacs of the lungs, causing low oxygen and high carbon dioxide). During a review of Resident 203's Care Plan titled Resident is at risk/has chronic obstructive pulmonary disease (COPD) and increases chance of rehospitalization, indicated the resident's goals were for the resident to minimized signs or symptoms of COPD through the next review with a plan to administer medication as ordered. During an observation on [DATE] at 8:32 a.m., on station two's medication room, there were two opened Ipratropium Bromide and Albuterol Sulfate Inhalation Solution 0.5 mg/ 3 mg per 3 ml vials (a combination medication used to treat and prevent shortness of breath) combination inhalation solution foil pack for Resident 203 had a fill date of [DATE] for one box and [DATE] for the second box. Both boxes were found stored at room temperature and not labeled with an open date on the foil pack. During a review of the manufacturer's product storage and labeling guidelines, indicated opened 555368 Page 20 of 40 555368 10/18/2021 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0761 Level of Harm - Minimal harm or potential for actual harm foil packs of ipratropium with albuterol inhalation solutions should be stored at room temperature between 36 to 77 degrees Fahrenheit and should be used or discarded within two weeks. During an interview with the Director of Staff Development (DSD) on [DATE] at 8:32 a.m., the DSD stated Resident 203 had expired (died) and they were supposed to discard the solutions, but they did not. Residents Affected - Some During an observation on [DATE] at 3:28 p.m., on station one medication cart 1, two open Ipratropium Bromide 0.5 mg/ 2.5 ml unit dose vials (a combination medication used to treat and prevent shortness of breath) inhalation solution foil pack with a fill date of [DATE] and a second box / foil pack with a fill date [DATE], for Resident 52 was found stored at room temperature and not labeled with a date on which foil pack was opened. During a review of the manufacturer's product storage and labeling guidelines indicated, open foil packs of ipratropium with albuterol inhalation solutions should be stored at room temperature between 36 to 77 degrees Fahrenheit and should be used or discarded within two weeks. During an interview with Licensed Vocational Nurse 1 (LVN 1) on [DATE] at 8:50 a.m., LVN 1 stated the breathing treatments for Resident 52 did not have an open date and it was important to have an open date because if expired, the medication would not be effective. During an interview with the Consultant Pharmacist (CP) on [DATE] at 9:23 a.m., stated the inhaler solutions are to be dated once the foil container is opened and all inhaler solutions are treated the same way, they are to be used within two weeks once opened. During an interview with the CP on [DATE] at 9:44 a.m., stated according to the manufactures guidelines and only based on their studies, the inhalation solution can only guarantee the preservatives (a substance used to preserve materials against decay) to remain effective for fourteen days within the solution, beyond that there is a risk of bacterial growth. During a review of the facility's policy and procedure revised 2021 and titled, Storage of Medications indicated staff shall place an open date on all medication that are open prior to use. 2. During a review of Resident 52's admission Record indicated Resident 52 was admitted to the facility on [DATE]. Resident 52's diagnosis included chronic obstructive pulmonary disease (is a disease that causes blocked airflow from the lungs). During a review of Resident 52's Care Plan titled Potential for impaired breathing pattern, shortness of breath, congestion wheezing, and respiratory distress indicated the resident goals were for resident to have optimal breathing patterns with a plan to administer breathing treatment pro re nata (P.R.N. when necessary) as ordered for shortness of breath. During a review of Resident 203's admission Record indicated Resident 203 was admitted to the facility on [DATE]. Resident 203's diagnosis included acute respiratory failure unspecified with hypoxia and hypercapnia (when fluid builds up in the air sacs of the lungs, causing low oxygen and high carbon dioxide). During a review of Resident 203's Care Plan titled Resident is at risk/has chronic obstructive pulmonary disease (COPD) and increases chance of rehospitalization indicated the resident goals were for 555368 Page 21 of 40 555368 10/18/2021 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resident to minimized signs or symptoms of COPD through next review with plan to administer medication as ordered. During an observation on [DATE] at 8:32 a.m., on station two's medication room, two open Ipratropium Bromide and Albuterol Sulfate Inhalation Solution 0.5 mg/ 3 mg per 3 ml vials (a combination medication used to treat and prevent shortness of breath) combination inhalation solution foil pack for Resident 203 with fill date of [DATE] for one box and [DATE] for second box. Both boxes where found stored at room temperature and not discarded. During a review of the manufacturer's product storage and labeling guidelines, opened foil packs of ipratropium with albuterol inhalation solutions should be stored at room temperature between 36 to 77 degrees Fahrenheit and used or discarded within two weeks. During an interview with the Director of Staff Development (DSD) on [DATE] at 8:32 a.m., the DSD stated Resident 203 had expired (died) and the facility was supposed to discard the solutions but did not. During an observation on [DATE] at 3:28 p.m., on station 1 medication cart, there was one open container of Ipratropium Bromide 0.5 mg/ 2.5 ml unit dose vial (a combination medication used to treat and prevent shortness of breath) inhalation solution foil pack fill date of [DATE], for Resident 52 was found stored at room temperature and not discarded. During a review of the manufacturer's product storage and labeling guidelines, opened foil packs of ipratropium with albuterol inhalation solutions should be stored at room temperature between 36 to 77 degrees Fahrenheit and used or discarded within two weeks. During an interview with Licensed Vocational Nurse 1 (LVN) on [DATE] at 8:50 a.m., LVN 1 stated the breathing treatments for Resident 52 did not have an open date and it was important to have an open date because if expired, the medication has been used and it would not be effective. During an interview with Consultant Pharmacist 1 (CP) on [DATE] at 9:23 a.m., CP 1 stated inhaler solutions are to be dated once foil container od any inhaler solution was opened it must be used within two weeks. During an interview with CP on [DATE] at 9:44 a.m., CP 1 stated according to the manufactures studies the inhalation solution can only guarantee the preservatives (a substance used to preserve materials against decay) to remain effective for fourteen days within the solution, beyond that there is a risk of bacterial growth. During a review of the facility's policy and procedure revised 2021 and titled, Storage of Medications indicated staff shall place an open date on all medication that are opened prior to use. 3. During an observation and concurrent interview on [DATE], at 07:03 a.m., the medication cart 2 stored a disinfectant wipe product next to the resident's medication bubble package. Licensed Vocational Nurse (LVN 6) stated the disinfectant wipes were stored with the resident's medication because the medication cart did not have any other space to store the resident's morning medications. During a review of the facility's undated policy titled Medication Storage, the policy indicated disinfectants and drugs for external use were stored separately from internal and injectable 555368 Page 22 of 40 555368 10/18/2021 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0761 medications. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 555368 Page 23 of 40 555368 10/18/2021 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to notify the physician in a timely manner and recheck an abnormal level of Depakote (a seizure medication) for one out of three residents (Resident 41). This deficient practice had the potential for Resident 41 to suffer adverse consequences (unwanted, uncomfortable, or dangerous effects that a drug may have such as impairment or decline in an individual 's mental or physical condition or functional and psychosocial status). Findings: During a review of the clinical records for Resident 41, the Face sheet indicated Resident 41 was originally admitted on [DATE] and was readmitted on [DATE]. Resident 41 diagnoses included epilepsy (a burst of uncontrolled electrical activity between brain cells (also called neurons or nerve cells) that causes temporary abnormalities in muscle tone or movements (stiffness, twitching or limpness), behaviors, sensations or states of awareness), schizoaffective disorder ( a chronic mental health condition characterized primarily by symptoms such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression), and hemiplegia (total or partial paralysis of one side of the body). During a review of Resident 41's History and Physical Examination record dated 12/12/20, indicated Resident 41 did not had the capacity to understand or make decisions. During a review of the Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 7/28/21, indicated the usually made himself understood and was usually able to understand others. The MDS indicated the resident required extensive one person assistance with bed mobility, dressing, toilet use, and personal hygiene. During a review of the Physician Orders dated 3/16/21 indicated the resident had an order for Depakote 750 milligrams (750 mg), orally, daily, for mood disorder manifested by sudden anger outburst. During a review of the Laboratory report dated 6/28/21, indicated the Depakote level for Resident 41 was 27 micrograms per milliliter ([ug/ml] unit of measurement). The laboratory report indicated the normal range for the Depakote was between 50-100 ug/ml. During a review of the Nurse's Note dated 6/29/21 and timed at 1 p.m., indicated an order to draw a Depakote level, was received and carried out. Another note written on 7/16/21 and timed at 7 p.m., indicated the physician asked the facility to fax the resident 's laboratory results to his office. The note indicated the laboratory was closed and the physician asked the facility to fax the residents' laboratory results the next day. The note indicated the facility was going to follow up on the results. During a concurrent interview and record review on 10/18/21 at 7:23 a.m., Licensed Vocational Nurse (LVN 8) stated, normal laboratory test results were faxed to the physician, but when he received an abnormal laboratory test result he called the physician and documented in the medical records. LVN 8 reviewed the Resident 41's Depakote laboratory results and stated the laboratory result was received on 6/28/21 but was reported to the physician late on 7/26/21. LVN 8 stated, he could not find 555368 Page 24 of 40 555368 10/18/2021 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few documentation of any new orders for the Depakote medication and he did not know if the facility had followed up with the physician about the medication abnormal level as he could not find any documentation. LVN 8 stated, the facility should have documented in the medical records and follow up with the physician about the abnormal result. During a review of the facility's policy titled Verbal orders revised on 2021, indicated the facility should follow through with the physician's orders by making appropriate contact or notification (e.g., lab or pharmacy). 555368 Page 25 of 40 555368 10/18/2021 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: Residents Affected - Some 1. Different types of Juices and milk in cups on a food cart in the walk-in refrigerator was not labeled with a date and name. 2. Two boxes of raw pork was on top of uncooked chicken in the walk-in refrigerator. 3. 7 wraps of waffle inside of the freezer was taken out of the original box, there was no receiving date or expiration date. 4. chicken nuggets and 11 boxes of egg rolls were in the freezer with no written expiration dates. 5. 8 cans of sweet pepper in the dry storage area had no expiration dates. 6. 4 containers of spices on the counter have no opening or expiration dates. 7. 1 container of seasoning salt on the counter with the expiration date of 10/3/21. 8. Food preparation and storage area were not maintained clean. The kitchen was cluttered with items, a bucket with dirty water and towel was sitting on the food preparation counter, one of the Kitchen sinks was cluttered with disposable trays and boxes. 9. Sanitizing solution was not mix according to manufactures' direction. 10. one cook had no hair cover on while in the food preparation area. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness for 89 out of 89 residents who received food from this kitchen. FINDINGS: 1. During a Kitchen tour observation on 10/13/21 at 8:15 a.m., Juices and milk in cups were observed on a food cart in the walk-in refrigerator. the juice in the cups were different colors and the milk were different textures. the cups were not labeled with names, types, and dates. In the freezer, 7 wraps of waffles with 4 in each wrap was observed with no expiration date, chicken nuggets in a zipped lock bag without expiration date, 11 boxes of vegetable egg rolls with no expiration date, In the dry storage, 8 cans of sweet pepper were observer on the counter with no expiration date. 4 containers of cooking spices were observed on the counter with no opening and expiration date. 1 container of seasoning salt was on the counter with expiration date of 10/3/21. 555368 Page 26 of 40 555368 10/18/2021 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The food preparation area was cluttered with items; stack of disposable trays and boxes were observed on the sink. During an interview on 10/13/21 at 10:20 a.m., with the dietary supervisor (DS) the DS stated, the juice in the cups were orange juice, apple juice and cranberry juice and the milk in the cups were regular and skim milk. The DS stated, each cup should be labeled with date and the name of the content. According to the DS, the undated food in the freezer and every item that were delivered should have a received date and an opened date once foods were opened. The DS stated, she could not find the received date on the frozen waffle, chicken nuggets and the vegetable egg roll. The DS stated foods that have a past written and used should be discarded. During concurrent observation and interview with the DS on 10/14/2021 at 2:30 p.m., a bucket with dirty water and a towel was observed on the countertop close to cooking stove. The DS stated the dirty bucket was left there by one of the staff after cleaning and it should be discarded immediately after use. During a concurrent observation in the kitchen on 10/14/21 at 2: 30 p.m., one of the cooks (cook 1) was observed not wearing a hair cover while preparing the dinner meal. During an interview on 10/14/21 3:05 p.m., with cook 1, cook 1 stated she forgot to cover her hair before entering the kitchen. During concurrent observation and interview with DS in the kitchen on 10/14/21 at 2:30 a.m., a black bucket was observed under the counter close to the cooking stove with towels. The DS stated the liquid in the bucket was the sanitizing solution. The DS tested the solution with a test strip, compare the test strip color to the concentration indicator on the test strip label. The DS stated, it's between 100-200 part per million (PPM). (PPM is a method uses in measuring concentration in a sanitizing solution). When asked by the surveyor what the correct concentration should be for effective sanitization the DS stated, it should be 200 ppm. During observation and interview with cook 2 on 10/14/21 at 3:10 p.m., cook 2 stated that the sanitizing solution in the bucket was mixed by the day shift staff and it should be changed every 2 hours. [NAME] 2 was observed: he poured the solution into the black bucket and cleaned the bucket. He then mixed a fresh solution by adding hot water into this same bucket and poured in the 'sani-10% disinfectant' into the bucket without measuring it. During interview with cook 2, he stated that he did not need to measure the amount of hot water and the sanitizer, he estimated the amount. During an interview with the DS on 10/14/21 at 3:36 p.m., the DS stated that the sanitizing solution should be prepared according to the manufacture's directions. According to the DS the correct measurement should be 1.2 tablespoon of sanitizer to 1 gallon of water. The mixed solution should be changed every shift. During a review of facility Policy and Procedure (P&P) titled Quaternary Ammonium Log Policy dated 2018, the P&P indicated that the concentration of the ammonium in the quaternary sanitizer will be tested to ensure the effectiveness of the solution. (Quaternary Ammonium is a type of chemical that 555368 Page 27 of 40 555368 10/18/2021 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some is used to kill bacteria, viruses and mold). The P&P also indicated the quaternary solution used for sanitizing clean surfaces in the kitchen will be made according to the instructions on the container. According to the P&P, the food and nutrition worker will place the solution in an appropriate bucket labeled for its contents. The concentration of the solution will be tested every shift or when cloudy and the result recorded on the quaternary ammonium log. It also indicated the solution will be replaced when the reading is below 200 ppm. During a review of facility's policy and procedure titled Food Receiving and Storage revised on 2021, the policy and procedure indicated that dry foods that are stored in the bins will be removed from original packaging, labeled, and dated 'use by date'. All food stored in the refrigerator or freezer will be covered, labeled, and dated 'use by date'. 555368 Page 28 of 40 555368 10/18/2021 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on interview, and record review, the facility's failed to follow its policy to ensure staff had the knowledge, capability, and capacity to perform their duties by not performing annual skills competency (measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) checklist as needed on 6 of 6 employee files. This deficient practice had the potential for 89 of 89 residents not being assisted, or provided medically related care and services, and could lead to serious injury, harm, impairment, or death. Findings: During a concurrent interview and record review on 10/18/2021 at 12:10 p.m., with the Director of Staff Development (DSD), employee files for License Vocational Nurse (LVN 2), Infection Preventionist (IP), Certified Nurse Assistant (CNA 2), CNA 7, CNA 8, CNA10 were reviewed. There were no :Skills Check list forms: found inside the employees' files. During an interview on 10/18/21 at 12:10 p.m., the DSD stated that employees should have an annual Skills Competency Check list inside their files upon being hired, annually and as needed thereafter to ensure the staff are competent in performing their duties. The DSD stated, he was responsible for ensuring the employee files were complete. Upon further review of the employee files by the DSD revealed, there were no Skills checklist found in the above mentioned employee's file. The DSD also stated, the Director of Nursing was responsible for assessing LVN's skills competency and the DSD was responsible for checking CNAs competencies. The DSD stated, he completed employee skills check list but gave it back to the employees and did not keep a record because he just started working as the DSD in March 2021, and was not aware that he should keep it on the employee file and will do the competency again. During an interview and concurrent record review of employee files with the DON on 10/18/2021 at 12:19 p.m., the DON stated, the Skills competency check list should be in the employee files and if it was not there, that means it was not done. The DON stated, she was responsible for doing the Skills competency for RNs and LVNs, the DSD does the Skills competency for CNAs but stated that they were not able to do it. The DON stated, the Skills Competency check list should be completed upon hire and annually to ensure the employees were competent and had the skills to perform their duty, safely while caring for the residents. The DON stated, the Skills Check list should be kept in the employee's file as proof to show the competency of the staff. During a review of the Facility Assessment form dated 09/30/2021, indicated the following information; the facility resources needed to provide competent support and care for resident population every day and during emergencies, facility will identify the type of staff members, other healthcare professional and medical practitioners that are needed to provide support and care for residents. Describe the training /education and competencies that are necessary to provide the level and types of support and care needed for your resident population. Include staff certification requirements as applicable. Potential data sources include hiring, education training, competency instruction and testing policies. The required in-service training for nurses aides must be sufficient to ensure the continuing competence of nurse aides-must be no less than 12 hours per year, to included dementia 555368 Page 29 of 40 555368 10/18/2021 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0838 Level of Harm - Minimal harm or potential for actual harm management training and resident abuse prevention training. The assessment indicated to address areas of weakness as determined in nurse aide's performance reviews. Staff training and competencies include the following : infection control, person centered care, activities of daily living, medication administration, specialized care like catheterization insertion/care, colostomy care, diabetic blood glucose testing, oxygen administration, tube feedings, wound care/ dressings. Residents Affected - Some During a review of the facility's policy and procedure titled, Staffing revised October 2017, indicated the facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and facility assessment. During a review of the facility's policy and procedure titled, Competency Evaluation revised 2019, indicated it is the policy of this facility to evaluate each employee to assure appropriate competencies and skills for performing his or her job and to meet the needs of the facility residents. Initial competency is evaluated during the orientation process, an employee remains on orientation until all competencies are verified. Subsequent and/or annual competency is evaluated at a frequency determined by the facility assessment, evaluation of the training program, and or job performance evaluation. Checklist were used to document training and competency evaluations. Employee competency forms are maintained in the Staff Development Coordinator's office for current training year, then forwarded to the Human Resources Director for placing into the employee's personnel file. 555368 Page 30 of 40 555368 10/18/2021 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0850 Hire a qualified full-time social worker in a facility with more than 120 beds. Level of Harm - Potential for minimal harm Based on interview and record review the facility's Social Services Director (SSD) failed to provide knowledge and understanding in regard to the Advanced Directive process. The SSD did not have an understanding about the facility's Advanced Directive process which was a minimum qualification for the SSD's job position, according to the facility's policy. Residents Affected - Some This deficient practice had the potential to violate residents' decisions for end-of-life decisions. Findings: During an interview with the Director of Social Services (DSS) on 10/14/21, at 12:17 p.m., she stated the POLST form had to meet the Advanced Directive acknowledgement form. The DSS stated, she completed the Advanced Directive acknowledgement form to all the residents because all the residents had to have this form. The SSD said, all residents should have the Advanced Directive acknowledge form in their chart, but she was unable to explain the reason for the form. The DSS stated, she completed the form for all residents, including residents who were not competent to make decisions because she thought they have to have the form. The DSS stated, she did not ask the residents who could not speak if they wanted to complete an Advanced Directive, but she did complete the form for some of the residents she had not asked as they could not speak. The DSS stated, she had not completed any college training to become a Social Services person. The DSS stated, she completed a course and obtained a Certificate for Social Services Designee. During a record review of the DSS certificate dated 6/14/2007, indicated the DSS obtained a social services certification program after completing a 36-hour workshop. The facility's Job Description titled Social Services Director revised 2021, indicated qualifications required to direct the social services department must be a minimum of a bachelor's degree in social work or another human services field. The job description indicated major duties and responsibilities included identifying the needs for medically related social services and ensure these services were provided according to state and federal regulation; coordinate implementation and oversight of procedures to ensure social services actions and interactions were properly documented in each resident's medical record, and that legal, ethical, and professional standards were upheld. It also indicated the Social Services Director was responsible for improving the safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving) plans of action to ensure the QAA/QAPI committee systematically implemented and evaluated the plan of action facility wide. 555368 Page 31 of 40 555368 10/18/2021 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 ([QAA] develop and implement appropriate plans of action to correct identified quality deficiencies) and Quality Assurance Performance Improvement ([QAPI] takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving) committee failed to develop and implement appropriate plans of action to ensure the QAA/QAPI committee systematically implemented and evaluated the plan of action facility wide to ensure housekeepers and genitors were following manufacturer's recommendation for use of disinfectant product when cleaning the facility. These deficient practices could result in the spread of COVID-19 (a highly contagious infection, caused by a virus that can easily spread from person to person) infection to residents, staff, and the public and prevent residents from receiving the quality treatments necessary to meet their highest potential well-being. Findings: The QAA/QAPI committee failed to ensure housekeeper and genitor were following manufacturer's recommendation for use of disinfectant product when cleaning the facility. During a QAPI interview on 10/18/21 at 11:52 a.m., the Director of Nurses (DON) stated the facility had discuss how to improve infection control practices, but they were not aware the housekeeping staff and genitors did not know how to properly use the disinfecting products and stated could be due to a language barrier. The facility's policy titled Quality Assurance Performance Improvement (QAPI) Plan dated 2021, indicated the facility was to systematically monitor, analyze, and improve its performance to improve resident outcome. The policy indicated the facility would identify areas for improvement and would review past facility measures to benchmark for improvements in all areas. 555368 Page 32 of 40 555368 10/18/2021 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

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's staff failed to implement their infection control interventions in accordance with the facility's infection control policies and procedures (P/P) and mitigation plan ([MP] a plan to reduce the spread of the Corona Virus ([COVID-19] a highly contagious virus that causes severe respiratory illness that affects the lungs and airways) by failing to: Residents Affected - Many 1a. Ensure the facility have a full-time, dedicated Infection Preventionist (IP) person who will monitor for compliance according to the infection control guidance. 1b. Ensure the Infection Preventionist wears eye protection, like a face shield or goggle and personal protective equipment ([PPE] protective devices that are worn to prevent the spread of infection) in the yellow zone (a unit for residents suspected of COVID-19) while assisting Resident 440 to use the bathroom. 1c. Ensure five (5) staff members inside the green zone, are wearing face shield when giving care or within 6 feet of resident. 1d. Ensure the housekeeper (HSK) is wearing the correct N95 size, face shield and changing gowns and gloves in between cleaning resident rooms inside the yellow zone. 1e. Ensure the staff (Janitor 1) properly wore the surgical face mask while in the facility. 1f. Ensure the staff (Janitor 1 and Housekeeping 1 [HK 1] follow the manufacturer guidance to disinfect the facility. 2. Ensure to clean a bedside table from another resident's room, before using it for Resident 1 during a medication administration observation. 3. Ensure tube feeding equipment is maintained, dated and cleaned for one of twenty-one residents, Resident 72. a. Ensure Resident 72's [NAME] Valve (device use to control the passage of fluid through a tube) was clean and changed. b. Ensure Resident 72's tube feeding pump was clean. c. Ensure to label the feeding tube for Resident 72. d. Ensure to follow their own policy regarding tube feeding solution hang time for one of four sampled residents, Resident 33, with a gastrostomy feeding tube (GT - a tube that is passed through the abdominal wall to the stomach used to provide nutrition) was not administered and was replaced per facility's policy for one of four residents (33). These deficient practices had the potential to result in the spread of COVID-19, foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) for Residents 33 and 72 and the resident not getting the required nutrition as order by their physicians. 555368 Page 33 of 40 555368 10/18/2021 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0880 Findings: Level of Harm - Minimal harm or potential for actual harm 1a. During an interview on 10/13/21 at 9:58 a.m., CNA 10 stated the Infection Preventionist (IP) was the charge nurse for Station 3 and the IP had been working at least 3 times a week as charge nurse. Residents Affected - Many During an interview on 10/13/2021 at 10:00 a.m., the IP stated she was the Infection Preventionist on 10/13/2021 and the charge nurse for Station 3 at the same time. The IP nurse stated, she was working as charge nurse at least 3 times a week and working as IP at the same time and no other person was designated to cover the IP role. The IP stated, she sometimes works more than 40 hours in a week, working as charge nurse and IP but there were weeks that she was not able to complete the 40 hours required to work as an IP but stated there was no additional coverage for the IP who was needed since the facility has no COVID 19 outbreak. During an interview on 10/14/21 at 9:28 a.m., The IP nurse was unable to state the current guideline and unable to state where to find the latest guideline for COVID 19. The IP state, the N95 (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of infectious particles in the air) can be worn for one week in the yellow and red zone area unless it becomes soiled. The IP also stated, she was not aware eye protection like face shield or goggles, personal protective equipment ([PPE] protective devices worn to prevent the spread of infection) was required when providing care for residents or when they are within 6 feet, near the resident. The IP also stated, she did not know what positivity rate (rate of infection in the community) was and has not been checking positivity rate. The IP stated, that her DON was the one who checks for the latest updates with COVID 19 and was relaying the messages to her. During a review of the Los Angeles County Guidelines for Preventing & Managing COVID-19 in Skilled Nursing Facilities, dated 10/1/2021, guidance requires eye protection, which can be goggles or face shields, should be worn when staff are providing resident care, within 6 ft of residents, or while in resident rooms in all cohorts. During an interview on 10/18/2021 at 11:33 a.m., the Director of Staff of Development (DSD) stated, since the IP was promoted on March 2021, he was not assigned to work as IP. The DSD stated, that he also needed to work as DSD and charge nurse when they were short of staff. During a review of the IP timecard records from 10/3/2021 to 10/9/2021, indicated the IP worked 45.58 hours from 10/3/2021 to 10/9/2021. During a review of the nursing staff assignment sheet records from 10/3/2021 to 10/9/2021 indicated, the IP was scheduled to work as the charge nurse on 10/4/2021, 10/6/2021, 10/9/2021 and was only scheduled to work as an IP on 10/3/2021. The assignment sheet did not indicate if there was IP covering the days the IP was working as charge nurse. During a concurrent interview and record review of the assignment sheets dated from 9/1/2021 to 10/15/2021, and the timecards for the IP from 9/1/2021 to 10/15/2021 at 2:53 p.m. The DON stated the IP was the only IP at the facility and had been working 8 hours as charge nurse and IP at the same time. The DON stated the staff were calling in sick and she had to ask the IP as a last resort to work as the charge nurse. The DON stated, the IP will sometime stay over to work as an IP but admitted the IP was not able to complete 40 hours working as an IP, the past couple of weeks due to staff calling in sick. 555368 Page 34 of 40 555368 10/18/2021 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a review of the facility's COVID-19 MP, revised on 6/15/2021, the MP indicated the Skilled Nursing Facility (SNF) has a full time, dedicated Infection Preventionist. An infection control lead has been designated to address and improve infection control based on public health advisories (Federal and State) and spends adequate time in the building focused on activities dedicated to infection control. During a review of the Los Angeles County Guidelines for Preventing & Managing COVID-19 in Skilled Nursing Facilities, dated 10/1/2021, guidance requires that facilities employ a full-time, on-site infection preventionist who will monitor compliance with infection control guidance. 1b. During an observation on 10/13/21 at 9:00 a.m., the IP was observed inside the yellow zone not wearing eye protection while talking and assisting Resident 440 to use the bathroom. During an interview on 10/18/21 11:00 a.m., IP stated she was not wearing face shield on yellow zone because she was only talking and assisting a resident to use the bathroom, but she admitted that she was less than 6 feet apart from Resident 440 because she needed to hold the resident while going to the bathroom. The IP stated, she should have worn eye protection while inside the yellow zone when staff were providing resident care, within 6 ft of residents, or while in resident rooms. During a review of the facility's COVID-19 MP, revised on 6/15/2021, the MP indicated all staff will wear recommended PPE while in the building per current California Department Public Health (CDPH) PPE guidance. During a review of the Los Angeles County Guidelines for Preventing & Managing COVID-19 in Skilled Nursing Facilities, dated 10/1/2021, guidance requires eye protection, which can be goggles or face shields, should be worn when staff are providing resident care, within 6 ft of residents, or while in resident rooms in all cohorts. 1c. During an observation and interview on 10/13/21 9:05 a.m., Certified Nurse Assistant 2 and 8 (CNA 2 and CNA8) were observed inside the green zone, in room [ROOM NUMBER]C, wearing surgical masks and gloves, but both were not wearing eye protection while cleaning and shaving the resident. CNA2 stated, they do not need to wear a face shield inside the green zone even when providing care or within 6 feet from the resident. She stated, she thought the face shield was only required in the yellow zone and not in the green zone, even while providing care. During an observation and interview on 10/13/2021 at 10:53 a.m., Certified Nurse Assistant CNA 3, (inside the green zone) room [ROOM NUMBER]B, was observed helping the resident get situated in bed without a face shield. During an interview CNA 3 stated, she just finished showering the resident and helping her back into bed. CAN 3 stated, the PPE inside the green zone includes surgical mask, hand washing and gloves. CNA3 stated, the face shields are only worn inside the yellow zone area to help prevent spread of infection. During an observation on 10/13/2021 at11:04 a.m., CNA3 was observed inside of room [ROOM NUMBER]B again, placing a blanket and tucking a resident in bed, without a face shield. During an observation and interview on 10/13/2021 at 12:52 p.m., Certified Nurse Assistant (CNA2) was observed feeding a resident and was not wearing a face shield. CNA2 stated, inside the green zone 555368 Page 35 of 40 555368 10/18/2021 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many she would only wear a face shield if she was cleaning a resident, but she does not need to wear one while feeding the resident. She stated, that the face shield is to help prevent the spread of virus. During an observation and interview on 10/14/2021 at 11:42 a.m., the Housekeeper (HSK) inside of the yellow zone was observed wearing Personal Protective Equipment (PPE) of green / blue N95 (BYD DE2322), gown and gloves with no face shield or googles. The HSK stated, she forgot to wear her face shield today, but PPE required in yellow zone includes N95 mask, face shield, gown, and gloves. During an interview on 10/18/2021 at 10:21 a.m., the Infection Preventionist Nurse (IP) stated that inside the green zone, PPE worn by staff includes surgical masks, gloves and face shield. She stated, face shield is needed with the evident a spill or bodily fluids and anytime providing resident care that is less than 6 feet apart. She also stated, this is important to prevent the spread of Covid-19 or any kind of virus. 1d. During an observation on 10/14/2021 at 11:42 a.m., the Housekeeper (HSK) inside the yellow zone was observed wearing Personal Protective Equipment (PPE) of greenish blue N95 (BYD DE2322), gown and gloves with no face shield or googles. The HSK was observed mopping from rooms 33 to room [ROOM NUMBER] and room [ROOM NUMBER], without wearing a face shield and without changing the PPE. During an interview on 10/14/2021 at 11:52 a.m., the HSK inside the yellow zone stated she forgot to wear her face shield today, but PPE required includes N95 mask, face shield, gown and gloves. She stated, she was N95 fit tested and the white one is her size, but she is wearing the greenish blue one, because it is what is available in the cart. The HSK stated, when cleaning the yellow zone, she changes gowns and gloves twice, once to clean the rooms and a second time to collect trash. She stated, she was not aware she had to change PPE in between rooms. During an interview and record review on 10/14/2021 at 2:52 p.m., a record review with the Director of Staff Development (DSD) regarding the HSK's N95 testing certificate, dated 3/30/2021, indicated that her N95 fit tested size is large without information regarding N95 make and/or model. The DSD stated, that the large size is the white N95, the medium size is the blue/green N95, and the small size is the duck looking N95. It's important to wear the proper fit size to protect resident and staff from spread of infection, certificate that checks off large are to wear the white N95. During an interview on 10/18/21 at 10:08 a.m., the Director of Nursing (DON) stated that staff cleaning in the yellow zone are required to wear PPE such as proper fit tested N95 size, face shield, gown, and gloves. She stated, the PPE should be changed in between cleaning rooms to prevent spread of germs and virus to avoid infection. During a review of the facility' s Mitigation Plan dated 6/15/2021, indicated staff have been educated and trained on Covid-19: symptoms, modes of transmission, complications, treatment /precautions, infection prevention measures, proper use of PPE's and the facility designated COVID-19 area .Staff will be trained on proper donning and doffing procedures, appropriate PPE .All staff will wear recommended PPE while in the building per current CDPH PPE guidance . During a review of the Los Angeles County's Coronavirus Disease 2019 Guidelines for Preventing and Managing COVID-19 in Skilled Nursing Facilities, updated 10/1/2021, indicated eye protection, which can be goggles or face shields, should be worn when staff are providing resident care, within 6 ft of residents, or while in the resident rooms in all cohorts .Gowns should be changed (donned and 555368 Page 36 of 40 555368 10/18/2021 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0880 Level of Harm - Minimal harm or potential for actual harm doffed) between every patient, included those in multi-occupancy rooms) regardless of the cohort .In the Yellow and Red Cohorts, all staff regardless of vaccination status should wear N95 respirators when providing resident care (e.g., entering resident room and/or within 6 ft of resident) .Initial and annual N95 respiratory fit testing is required for all staff per California Division of Occupational Safety and Health (Cal-OSHA). Residents Affected - Many During a review of the California Occupational Safety and Health ([Cal/OSHA], a program responsible for enforcing California laws and regulations pertaining to workplace safety and health) guidance on COVID-19 for Health Care Facilities: Severe Respiratory Supply Shortages dated 8/2020 indicated employers must implement work practices to minimize the number of employees exposed to suspected and confirmed COVID-19 residents. The guidelines also indicated initial respirator fit testing was required before an employee used a respirator, or when an employee changed to a different model, make, or size of respirator. According to the guidelines, annual respirator fit testing was required by all facilities. 1e. During a concurrent observation and interview on 10/13/21, at 11:57 a.m., Janitor 1 was mopping the recreation room with his surgical mask below his nose. Janitor 1 walked to the supply room and showed me his cleaning products while continuing to have his face mask below his nose. Janitor 1 stated, his mask should have been over his nose to prevent him from catching or spreading infection in the facility. During an interview on 10/18/21 at 7:02 am, the Supervisor of Housekeeping stated the staff had to properly wear the face mask in the facility. The Los Angeles Department of Public Health (DPH) Skilled Nursing Facilities B73 COVID-19 Procedural Guidance updated 10/1/21, indicated all staff, regardless of vaccination status, must always wear a medical-grade surgical/procedure mask or N95 respirator for universal source control while in the facility. The facility's policy titled Covid-19 Mitigation Plan undated, indicated all the staff would wear a face mask while in the facility and were trained on how to properly put on personal protective equipment ([PPE] equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses). The mitigation plan indicated all the staff would wear the recommended PPE while in the building . 1f. During a concurrent observation and interview on 10/13/21 at 11:57 a.m., Janitor 1 stated he used Maxi-san disinfectant to clean high touch surfaces. Janitor 1 stated, he sprayed the product on the surface and immediately wiped the product from the surfaces. Janitor 1 stated, he did not know what the contact time (time the product should be in contact with the surface to disinfect the surface) for the product he was using. During a concurrent observation and interview on 10/13/21 at 12:10 a.m., HK1 showed the surveyor the Clorox healthcare Fuzion product which she uses to clean the high touch surfaces. HK 1 demonstrated how she used the product by spraying the product on a towel and wiping a cart surface. HK 1 stated, there was nothing else she had to do to disinfect a surface. HK 1 stated, she did not know how long the product had to be in contact to the surface. HK 1 read the product label which indicated to thoroughly spray the surface. HK 1 stated, she was not following the label instructions. During an interview on 10/18/21 at 7:02 a.m., Supervisor Housekeeper (SHK) stated the disinfectant 555368 Page 37 of 40 555368 10/18/2021 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many products were sprayed on the surface and let the product sit before whipping it down. The SHK stated, Clorox healthcare fusion contact time was two and half minutes. SHK stated, it was important to follow the product contact time to kill the viruses. During a review of the Maxi-San Disinfectant 1 oz Dilution label indicated, the product had a 10-minute contact time. The label on the Clorox Healthcare Fuzion Cleaner Disinfectant indicated, to clean and disinfect the surface, spray the surface until thoroughly wet and allow the product to remain wet for one minute. The Los Angeles Department of Public Health (DPH) Skilled Nursing Facilities B73 COVID-19 Procedural Guidance updated 10/1/21, indicated the facility should follow the disinfectant manufacturer direction. 2. During a medication administration observation on 10/14/21 at 9:45 a.m., with Licensed Vocational Nurse 6 (LVN), LVN 6 was observed getting Resident 1's medication ready to be administered through a gastrostomy tube [(G. tube) a tube placed into the stomach through the abdomen for feeding, medication administration and hydration]. LVN 6 needed a bed table to place Resident 1's medications, and LVN 6 went into another room with 2 residents, brought out a bed side table, took it into Resident 1's room, without sanitizing the table and placed the medications and cups with water on top of the table and proceed to administering the medicines to the resident through the G. tube. During an interview on 10/14/21 at 1:55 p.m. with LVN 6, LVN 6 stated that he should have wiped the bed table with a Sani wipe before taking it into Resident 1's room to prevent cross contamination and exposure to infection. 3. a. During a review of Resident 72's admission Record indicated, the resident was admitted to the facility on [DATE]. Resident 72's diagnoses included iron deficiency (lack of) and encounter for attention to gastrostomy (attention to artificial opening to stomach). During a review of Resident 72's History and Physical (H/P) record dated 11/13/2020, indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 72's Care Plan titled Potential for aspiration do to use of gastric (stomach) feeding indicated the resident goals were for resident to not have aspiration in the next three months, plan to gastric tube feed as ordered. During a review of Residents 72's Minimum Data Set ([MDS] a resident assessment and care planning tool) dated 9/10/2021, indicated the resident received 51% or more total calories through parenteral (administered or occurring elsewhere in the body than the mouth) or tube feeding (providing nutrition through a tube into the stomach). The MDS also indicated, the resident's average fluid intake was 501 cubic centimeters (cc) per day or more by Intravenous ([IV] through a vein) or tube feeding. During an observation on 10/13/2021 at 10:24 a.m., the resident's Lopez valve had brown/black residual connecting to the PEG tube (tube that connects to the wall of the abdomen directly into the stomach). During an observation on 10/15/2021 at 8:03 a.m., the [NAME] Valve remained not changed and the pump remain dirty. 555368 Page 38 of 40 555368 10/18/2021 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview with Licensed Vocational Nurse 6 (LVN 6) stated, they had to change all tubing and label all tubing within 24 hours. LVN 6 stated, they needed to label tubing otherwise they would not know when it would expire and not knowing when to change it, it could lead to risk for infection. During an interview with the Director of Nursing (DON) on 10/15/2021 at 11:57 a.m. stated, all parts of the tube feeding system must be label, including the formula tubing attached to the pump. The [NAME] Valve must be changed if it is dirty and has residue on it. Not following these steps could lead to infection. During a review of the facility's policy and procedure revised 2021 and titled, Enteral Tube Feeding via Continuous Pump indicated under general guidelines label formula, tubing, and syringe. 4. During a review of Resident 33's admission record indicated, the resident was admitted to the skilled nursing facility on [DATE] with diagnoses including, Cerebral Infarction (also known as a stroke) refers to damage to tissues in the brain due to a loss of oxygen to the area, dysphagia (difficulty swallowing) and Hemiplegia (paralysis on one side of the body). During a review of the Minimum data Set (MDS - a comprehensive assessment and care screening tool), dated 4/2/2021, indicated Resident 33 had impaired cognitive skills for daily decision making and required extensive assistance from staff for personal hygiene and bathing. According to this record Resident 33 makes inaudible sounds and points at things to make needs known. During a review of the Physician's Order dated 4/26/2021 indicated, to provide Resident 33's tube feeding of Jevity 1.5 calories at 70 cubic centimeters per hour cubic centimeters (cc) per hour for 12 hours by pump to provide 840 cc/1260 kilocalories per day. Start feeding at 7 p.m. and off at 7 a.m. or until dose complete. The Physician's Order was resumed from the previous order written on 10/23/2020. During a review of Resident 33's nutritional care plan initiated on 10/23/2020, indicated the resident should have received the tube feeding from 7 p.m. to 7 a.m. and to provide a therapeutic diet, fortified puree with no added salt, consistent carbohydrate additional as ordered by the Physician on 10/23/2020. During an observation on 10/13/2021 at 9:55 a.m., Resident 33 was awake and lying supine (on the back) in bed, unable or refused to speak at this time. The tube feeding (TF) solution of Jevity 1.5 was dated for 10/11/2021 at 10 p.m., with no initials of the staff who had started the tube feeding recently. The tube feeding found turned off with the remaining 700cc in the canister. During an observation on 10/13/2021 at 2:22 p.m., the same TF solution was hanging and had not been changed nor turned on to be infused. During an observation on 10/14/2021 at 10:20 a.m. noticed a new TF solution was seen hanging on the pole for Resident 33 dated October 13, at 7 p.m. at 70 cc/hr for 12 hours. During an interview with LVN 6 on 10/14/2021 at 3:12 p.m., LVN 6 stated, the TF solution that was already spiked and infusing, must be changed every 24 hours. LVN 6 also stated, the evening shift checked and changed the solution at 7 p.m. and turn off at 7 a.m. The syringe is changed as well. 555368 Page 39 of 40 555368 10/18/2021 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview with LVN 1 on 10/14/2021 at 3:20 p.m. LVN 1 stated, TF is changed when it runs out or not more than 24 hours. LVN 1 stated, TF will decay, gets spoiled, and will cause infection. The syringe is changed by the night shift. During a concurrent observation and interview with LVN 6 on 10/15/2021 at 8:20 a.m. it was observed that the TF line was connected to the TF solution canister and ready to infuse but was not connected to the resident. The TF solution canister was labeled and dated 10/15/2021 at 7 p.m. LVN 6 stated he just changed TF line this am but made a mistake on time. According to LVN 6, it's the evening shift that change the TF. When asked who changed it, LVN 6 said it was him. LVN 6 stated, night shift asked him to change this morning. When asked why he prepared the TF at 7 a.m. when it will not be turned on until 7 p.m. that night, LVN 6 did not answer and walked away. LVN 6 then returned to throw away the TF solution. During an interview with the Director of Nursing (DON) on 10/15/2021 at 3:01 p.m., the DON stated the TF solution is good for 24 hours, usually the 11-7 shift change the feeding, if not changed on the 3-11 shift. They must change it after 24 hours because it can be spoiled, bacteria can grow, and can make resident sick. During a review of the facility's policy and procedure titled Enteral Tube Feeding via (by) Continuous Pump under General Guidelines number 4, indicated refrigerate formulas that have been reconstituted in advance and discard within 24 hours. 5. During a concurrent interview and record review on 10/14/21 02:51 pm, with the DSD, the DSD stated the N95 testing log and Certificate issued to staff did not indicate the brand name or model number of the respirator, for which each staff had been fit tested. The DSD stated the large N95 was in the white (Honeywell), the medium was the blue/green (Byd), and the small was the duck ([NAME]-[NAME] Corp). The DSD also stated, he did not know why there was no documentation of the specific type of N95 used to test staff because fit testing was done by the facility's corporate staff. The DSS added that it should have been indicated for proper identification and prevent the spread of COVID-19. 555368 Page 40 of 40