Health inspection·February 7, 2025

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to: Residents Affected - Few 1. Ensure call light device was placed within reach for one of 18 sampled residents (Resident 56). This deficient practice had the potential to result in a delay in or an inability for the residents to obtain necessary care and services. Findings: During a review of Resident 56's admission Record, the admission Record indicated, Resident 56 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 56's diagnoses included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act), schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 56's History and Physical (H&P), dated 4/30/24, the H&P indicated Resident 56 had fluctuating capacity to understand and make decisions. A review of Resident 56's Minimum Data Set (MDS - a federally mandated resident assessment tool)), dated 1/24/25, indicated Resident 56 was assessed to have comprehend (the action or capability of understanding something) most conversation. The MDS indicated Resident 56 required supervision or touching assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as oral hygiene, showering, sit to stand, chair/bed-to-chair transfer, and toilet transfer. During a concurrent observation and interview on 2/4/25 at 2:50 p.m. with Certified Nursing Assistant (CNA) 1 in Resident 56's room, the resident call lights was hanging on the overhead light above Resident 56's bed, not within reach for the resident. CNA 1 stated the call light was not within reach for the Resident 56. CNA 1 stated the call light should be next to him for an emergency. CNA 1 stated if the call light was not within reach the resident could potentially fall, have breathing issues and not get the help they needed. During an interview on 2/7/25 at 9:06 a.m. with the Director of Staff Development (DSD), DSD stated if the call light were not within reach the resident could not get the help they needed in case of an emergency. Page 1 of 24 555368 555368 02/07/2025 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 2/7/25 at 10:28 a.m. with the Director of Nursing (DON), the DON stated the call light should always be within reach for the resident. The [NAME] stated it would potentially be dangerous for the resident not able to call for help when it was needed. During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light, (undated), the P&P indicated, when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. 555368 Page 2 of 24 555368 02/07/2025 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to: Residents Affected - Few 1. Conceal a sign containing personal information for one of two residents, (Resident 44), by posting it on the wall above the resident's bed. This deficient practice violated the resident's right to have personal information shielded from public view. Findings: During an initial tour on 2/4/2025 at 10:13, a handwritten sign disclosed Law enforcement device to be plugged in was posted above the Resident's 44 bed. During a review of Resident 44's admission Record, the admission record indicated the facility admitted Resident 44 on 2/22/2019 and re-admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty breathing), epilepsy (a chronic disorder characterized by recurrent, unprovoked seizures), and schizophrenia (a mental disorder characterized by disturbances in thought). During a review of the MDS, the MDS indicated Resident 44 rarely/never had the ability to express ideas and wants and rarely/never had the ability to understand others. The MDS also indicated Resident 44 was dependent (helper does all the effort) in all functional abilities. During a concurrent observation and interview on 2/6/2025 at 10:29 am at Resident 44's bedside with CNA 3, CNA 3 stated she was on staff when Resident 44 was originally admitted with the device, and the sign above his bed has been on the wall the whole time. CNA 3 stated the sign probably should not be there with Resident 44's personal information on it. The nurses leave it plugged in because the police come looking for Resident 44 when the battery dies. During a concurrent observation and interview on 2/6/2025 at 1:00 pm with Licensed Vocational Nurse (LVN) 4, at Resident 44's bedside, LVN 4 stated the sign placed above the bed states the resident has a device from a law enforcement agency. LVN 4 stated the sign is indicating Resident 44 has some issues with the law. LVN 4 also stated the sign above the bed does not protect Resident 44's privacy and it should have been placed in his chart. During an interview on 2/7/2025 at 2:34 pm with the Director of Nursing (DON), the DON stated the sign above Resident 44's bed is a violation of his privacy. The DON also stated the sign was there when she started working at the facility one year ago and she never questioned it. The last time an agent came out to check the devices' power, she asked about it and the agent stated it was court ordered and the sign needs to be posted so facility staff know it needs to be kept charged. During a review of the facility's policy and procedure (P&P) titled Posting Signs Policy, undated, the P&P indicated all signs posted within the facility shall comply with regulatory requirements. The P&P also stated signs with confidential resident information shall be displayed discreetly or in restricted areas only. 555368 Page 3 of 24 555368 02/07/2025 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure care plan interventions for two of four sampled residents (Residents 44 and 90) were implemented. The facility failed to implement: 1. Resident 44's care plan interventions regarding skin care for an ankle monitor. 2. Resident 90's care plan interventions regarding the resident leaving the facility temporarily with family. These failures placed Resident 44 and 90 at risk of not having their needs being met. Findings: a. During a review of Resident 44's admission Record, the admission Record indicated the facility admitted Resident 44 on 2/22/2019 and re-admitted on [DATE] with diagnoses including COPD, epilepsy, and schizophrenia (a mental disorder characterized by disturbances in thought). During a review of the Minimum Data Set (MDS - a resident assessment tool), dated 11/22/2024, the MDS indicated Resident 44 rarely/never had the ability to express ideas and wants and rarely/never had the ability to understand others. The MDS also indicated Resident 44 was dependent (helper does all the effort) in all functional abilities. During a concurrent observation and interview on 2/6/2025 at 10:29 am with Certified Nursing Assistant (CNA) 3, at Resident 44's bedside, Resident 44 was observed asleep. There was a brown electrical cord and black electrical power pack hanging from the foot of the bed. CNA 3 stated the plug was for Resident 44's ankle monitor and was unplugged during hygiene care and the charge nurses are responsible for keeping it charged. CNA 3 also stated the device has been connected to Resident 44's left ankle since he was admitted and if it runs out of power, the police show up to make sure Resident 44 is still in the facility. During a concurrent observation, interview, and record review on 2/6/2025 at 1:00 pm with Licensed Vocational Nurse (LVN) 4, at Resident 44's bedside, LVN 4 confirmed the presence of the ankle monitor on the left and stated there should be some material between it and the skin to protect from skin breakdown. At the nursing station, LVN 4 confirmed there was no care plan in Resident 44's health record regarding the ankle monitor. During an interview on 2/6/2025 at 2:20 pm with the Social Services Director (SSD), the SSD stated no paperwork was given to the facility by law enforcement regarding Resident 44's ankle monitor and that it was present on admission. The SSD stated there should be some paperwork in his chart regarding the device in case of emergency. During an interview on 2/7/2025 at 2:34 pm with the Director of Nursing (DON), the DON stated she does not know why Resident 44 has an ankle monitor. Everyone knows the device is there and no one has reported any skin issues. DON also stated there should be a care plan to ensure there is no skin break down. 555368 Page 4 of 24 555368 02/07/2025 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of the facility's P&P titled Comprehensive Care Plans, undated the P&P indicated that it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident that addresses a resident's medical, nursing, and mental and psychosocial needs. b. During a review of Resident 90's admission Record, the admission Record indicated the facility admitted Resident 90 on 12/11/2024 with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty breathing) , epilepsy (a chronic disorder characterized by recurrent, unprovoked seizures), major depressive disorder (a condition that involves persistent feelings of sadness and hopelessness), and paranoid schizophrenia (feelings of distrust and suspicion of others for no reason in addition to hearing or seeing things that are not there). During a review of the MDS, dated [DATE], the MDS indicated Resident 90 had the ability to express ideas and wants and had the ability to understand others. The MDS also indicated Resident 90 was independent with self-care and mobility (walking). During a review of Resident 90's Order Summary Report dated 2/1/2025, the report indicated an order on 12/11/2024 the resident may go for temporary leave of absence with companion and on indicated on 12/25/2024 the resident may go out for temporary leave of absence with family as needed. During a concurrent interview and record review on 2/7/2025 at 9:42 am with LVN 1, LVN 1 stated there should be an order and care plan for residents leaving the facility. The MDS Nurse is responsible for the care plan initiation. During a review of Resident 90's care plan, initiated 12/13/2024, LVN 1 did not see a focus area with goals and interventions for leaving the facility temporarily. LVN 1 stated he did not know how the residents' safety would be ensured while out of facility, but a care plan indicating goals and interventions would help. During an interview on 2/6/2025 at 1:50 pm with the MDS Nurse (MDSN), the MDSN stated he is responsible for care plan initiation and licensed nurses and other administrators can make revisions. MDSN stated he never thought of doing a care plan for residents leaving the facility temporarily but thinks there should at least be an assessment done when they leave and when they come back. During a review of the facility's policy and procedure (P&P) titled Out on Pass Policy, undated, the P&P indicated individuals who leave the facility on a temporary pass shall do so in a manner that ensures their safety, maintains proper documentation, and upholds facility guidelines. 555368 Page 5 of 24 555368 02/07/2025 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0657 Level of Harm - Minimal harm or potential for actual harm Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to: Residents Affected - Few 1.Ensure one out four sampled residents (Resident 57) had a revised care plan for oxygen therapy (the medical practice of providing a patient with supplemental oxygen). This deficient practice of not having a revised care plan to indicate when to administer oxygen therapy placed Resident 57 at risk of not meeting the care plan goal as indicated. Findings: During a review of Resident 57's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 57 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 57's diagnoses included chronic obstructive pulmonary disease ([COPD]- a chronic lung disease causing difficulty in breathing), respiratory failure (when the body's respiratory system is unable to exchange oxygen and carbon dioxide properly), and chronic heart failure (a condition where the heart can't pump blood efficiently). During a review of Resident 57's History and Physical (H&P), dated 12/20/2024, the H&P indicated, Resident 57 did not have capacity to understand and make decisions. During a review of Resident 57's Minimum Data Set ([MDS] a resident assessment tool), dated 1/15/2025, the MDS indicated Resident 57's cognition (ability to learn, reason, remember, understand, and make decisions) was moderately impaired. The MDS indicated Resident 57 was substantial assistance on staff for showering, dressing, and personal hygiene. The MDS indicated Resident 57 health condition included shortness of breath (trouble breathing) with exertion (walking, bathing, transferring, and when lying flat. During a review of Resident 57's physician orders titled, Order Summary Report, dated 12/10/2024, the physician orders indicated oxygen at two liters ([L] -a metric unit of measurement used to calculate volumes) per minute continuously every shift for shortness of breath and wheezing (a high-pitched whistling sound that indicates a person may be having trouble breathing). During a review of Resident 57's care plan titled, Risk for Shortness of Breath due to Chronic Respiratory Failure, dated 10/10/2024 the care plan indicated Resident 57 goals were not to have shortness of breath. The care plan interventions indicated to have oxygen available if ordered or as needed. During a concurrent interview and record review on 2/5/2025 at 12:32 p.m. with Minimum Data Set (MDS) Nurse, Resident 57's care plan titled, Risk for Shortness of Breath, dated 10/10/2024 was reviewed. The care plan goal indicated Resident 57 will have no shortness of breath daily. The care plan interventions indicated to have oxygen available if ordered or as needed. The MDS Nurse stated the care plan interventions should have been revised to state the frequency, route, when to change the nasal canula (a thin, flexible tube that delivers oxygen to a patient through their nose), and humidifier (a device that adds moisture to oxygen to prevent irritation of the nose and throat). The MDS 555368 Page 6 of 24 555368 02/07/2025 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Nurse stated it was important to revise the care plan so the staff will know when to give the oxygen such as when the saturation (measures the amount of oxygen in a patient's blood) is too low. The MDS Nurse stated it was also important to know when to change the nasal canula and humidifier. The MDS Nurse stated with incomplete interventions could affect Resident 57's care plan goals therefore the goal will not be met. During a review of facility's policy and procedure (P&P) titled, Reviewing and Revising the Care Plan, date unknown, the P&P indicated the purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. The P&P indicated the care will be updated with the new or modified interventions. The P&P indicated the care plans will be modified as needed by the MDS Coordinator or other designated staff member. 555368 Page 7 of 24 555368 02/07/2025 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 interview, and record review, the facility failed to: Residents Affected - Few 1. Properly obtain orthostatic blood pressure (a form of low blood pressure that happens when standing after sitting or lying down) readings for two of four sampled residents (Resident 3, Resident 52). This deficient practice had the potential for Resident 3 and Resident 52 to experience a delay in interventions if they were positive for orthostatic hypotension (low blood pressure). Findings: a. During a review of Resident 3's Face Sheet, it indicated Resident 3 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 3's Care Plan, dated 11/7/2024 it indicated Resident 3 had hypertension (high blood pressure) and an intervention included to monitor for side effects of blood pressure medications by checking orthostatic hypotension. During a review of Resident 3's Order Summary, an order was placed on 10/5/2024 to monitor orthostatic blood pressure sitting and lying weekly on Saturday in the evening. During a review of Resident 3's Blood Pressure Summary, dated 1/2025- 2/2025, Resident 3 had the following blood pressure recorded: 2/1/2025 6:40 p.m. 128 / 70 millimeters per mercury (mmHg- unit of measurement) Lying 2/1/2025 6:40 p.m. 136 / 84 mmHg Sitting 2/1/2025 8:14 a.m. 140 / 80 mmHg Sitting 555368 Page 8 of 24 555368 02/07/2025 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0658 1/25/2025 7:28 p.m. Level of Harm - Minimal harm or potential for actual harm 128 / 70 mmHg Lying Residents Affected - Few 1/25/2025 7:27 p.m. 136 / 80 mmHg Sitting 1/25/2025 9:01 a.m. 124 / 71 mmHg Sitting 1/25/2025 9:00 a.m. 124 / 71 mmHg Sitting 1/18/2025 8:24 p.m. 128 / 74 mmHg Lying 1/18/2025 7:24 p.m. 136 / 80 mmHg Sitting 1/18/2025 9:03 a.m. 140 / 61 mmHg Sitting b. During a review of Resident 52's Face Sheet, it indicated Resident 52 was originally admitted on [DATE] and readmitted on [DATE] with a diagnosis that included schizophrenia. During a review of Resident 52's Care Plan, dated 12/3/2024 it indicated Resident 52 had hypertension and an intervention included to monitor for side effects of blood pressure medications by checking orthostatic hypotension. 555368 Page 9 of 24 555368 02/07/2025 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0658 Level of Harm - Minimal harm or potential for actual harm During a review of Resident 52's Order Summary, an order was placed on 1/3/2025 to monitor orthostatic blood pressure sitting and lying weekly on Saturday in the evening. During a review of Resident 52's Blood Pressure Summary, dated 1/2025- 2/2025, Resident 52 had the following blood pressure recorded: Residents Affected - Few 2/1/2025 10:40 p.m. 122 / 80 mmHg Lying 2/1/2025 10:40 p.m. 120 / 60 mmHg Sitting 1/25/2025 11:22 p.m. 116 / 84 mmHg Lying 1/25/2025 11:21 p.m. 122 / 60 mmHg Sitting 1/18/2025 6:14 p.m. 120 / 76 mmHg Lying 1/18/2025 6:12 p.m. 134 / 76 mmHg Lying 1/11/2025 10:19 p.m. 108 / 60 mmHg Sitting 1/11/2025 10:15 p.m. 122 / 66 mmHg 555368 Page 10 of 24 555368 02/07/2025 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0658 Lying Level of Harm - Minimal harm or potential for actual harm 1/4/2025 9:16 p.m. 120 / 66 mmHg Residents Affected - Few Lying 1/4/2025 9:15 p.m. 122 / 74 mmHg Sitting During an interview on 2/6/2025 at 1:35 p.m. with Registered Nurse (RN) 1, RN 1 stated the method to take orthostatic blood pressure is by taking a blood pressure reading with the resident lying down first. Then, they would sit up and have them sit for about 5 minutes and take another blood pressure reading. RN 1 stated you must wait about 5 minutes between the position change to allow for their body to adjust to the change in position. RN 1 stated the nurse will report to the physician if there is a change of over 20mm/Hg for During a concurrent interview and record review on 2/6/2025 at 1:48 p.m. with RN 1, Resident 3 and Resident 52's Blood Pressure Summary dated 1/2025- 2/2025 was reviewed. RN 1 stated in some of the blood pressure documentation, the time they were taken was only 1 minute apart and that is not correct because the nurse needs to wait about 5 minutes from the lying to sitting position to allow the body to adjust to the change, not doing so means it is an inaccurate reading. RN 1 further stated according to the documentation of the blood pressure, the staff who took the readings took it in the sitting position first and then lying. RN 1 stated this method is incorrect and stated the first blood pressure reading should be lying first and then sitting and doing it in the reverse order is not how orthostatic blood pressure readings are to be taken. If it is done incorrectly, the nurse wouldn't know if the resident had orthostatic hypotension. During a review of the facility's policy and procedures (P&P), titled Orthostatic Hypotension Policy, undated, it indicated individuals are advised to change positions gradually, moving from lying to sitting before standing to prevent sudden drops in blood pressure, and blood pressure shall be measured in three positions- lying, sitting, and standing. 555368 Page 11 of 24 555368 02/07/2025 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **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. Ensure one of four sampled residents (Resident 32) was supervised and wore a smoking apron during smoking break. This deficient practice had the potential to put residents at risk for injury due to lack of supervision and maintain proper safety precautions while smoking. Findings: During a review of Resident 32's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission record indicated, Resident 32 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 32's diagnoses included cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain), schizophrenia (a mental illness that is characterized by disturbances in thought), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 32's History and Physical (H&P), dated 2/4/25, the H&P indicated Resident 32 did not have the capacity to understand and make decisions. During a review of Resident 32's Care Plan for smoking, initiated on 2/4/25, the care plan indicated, the resident would not smoke without supervision. The care plan also indicated, the resident required a smoking apron while smoking., During a review of Resident 32's Smoking Assessment Form, dated 2/4/25, the Smoking Assessment Form indicated, resident must be supervised at all times and wear protective non-flammable smoking apron when smoking. During a concurrent observation and interview on 2/4/25 at 3:15 p.m. with the Assistant Activities Director (AAD), in the dining room next to the opening to the sliding glass door where the residents were smoking. Resident 32 was sitting in the wheelchair in the smoking patio with her back to the sliding glass door, and not wearing a smoking apron. The AAD stated Resident 32 needed supervision and a smoking apron. AAD stated when Resident 32's cigarette was lit the smoking apron should have been put on, and resident should have been facing the sliding glass door. AAD stated it is important to place the smoking apron and supervise while smoking for the resident's safety. AAD stated this was to help prevent resident from harm, such as getting burned or starting a fire. During an interview on 2/4/25 at 4:00 p.m. with the Activities Director (AD), AD stated the activity staff does not smoke so we supervise by the opening of the sliding glass door. Residents who need supervision should be facing forward so we can supervise them. AD stated that Resident 32 back was facing he door and did not have on a smoking apron. AD stated that Resident 32 did need supervision and a smoking bib. AD stated this was not a way to supervise her, she should have had a smoking apron on and facing the door. AD stated that resident did have a napkin on lap while smoking this is a huge safety hazard. AD stated there was potential for resident to drop cigarette, burn herself or 555368 Page 12 of 24 555368 02/07/2025 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0689 start a fire. Level of Harm - Minimal harm or potential for actual harm During an interview on 2/7/25 at 10:28 a.m. with the Director of Nursing (DON), the DON stated smoking assessments let us know if the resident was a safe smoker or needed interventions such as supervision and smoking aprons. The DON stated the actives staff oversaw giving and lighting cigarettes, placing smoking aprons, and supervising resident while smoking. The DON stated that if there was not proper supervision, or if the resident was not wearing a smoking apron when needed, it was a safety issue. The DON stated there was a potential for harm to the resident, the resident could burn their clothes, skin, or even start a fire. Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled, Resident Smoking, (undated), the P&P indicated, facility provides a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment, to determine whether or not supervision is required for smoking, or if resident is safe to smoke at all. Supervision will be provided as indicated on each resident's care plan. 555368 Page 13 of 24 555368 02/07/2025 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to: Residents Affected - Few 1. Ensure one out of four sampled residents (Resident 84) was administered pain medication as needed. This deficient practice of not administering pain medication for Resident 84 had the potential to increase pain and discomfort. Findings: During a review of Resident 84's admission Record (Face Sheet), the Face Sheet indicated Resident 84 was admitted to the facility on [DATE]. Resident 84's diagnoses included cervicalgia (neck pain or discomfort in the upper spine), idiopathic neuropathy (a condition where nerve damage occurs with no identifiable cause), and anxiety (a feeling of apprehension or dread that can be caused by a real or perceived threat). During a review of Resident 84's History and Physical (H&P), dated 11/24/2024, the H&P indicated Resident 84 had the capacity to understand and make decisions. During a review of Resident 84's Minimum Data Set ([MDS] a mandated assessment tool), dated 12/28/2024 the MDS indicated, Resident 84's cognition (ability to learn, reason, remember, understand, and make decisions) he was able to understand. The MDS indicated Resident 84 was independent with personal hygiene, dressing, and eating. The MDS indicated Resident 84's numeric rating scale (a system where patients rate their pain intensity using numbers on a scale from 0 to 10, with 0 representing no pain and 10 representing the worst pain imaginable) of pain intensity was seven out of ten and had the potential to interfere with day-to-day activities. During a review of Resident 84's controlled drug record, titled Antibiotic or Controlled Drug Record, dated 11/30/2025 the Antibiotic or Controlled Drug Record indicated to give one tablet of tramadol 50mg every six hours as needed for severe pain. The Antibiotic or Controlled Drug Record indicated tramadol 50mg was removed on 11/30/2025 at 5:00 p.m. During a review of Resident 84's Electronic Medication Administration Record ([eMAR]- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 11/30/2024, the eMAR indicated on 11/30/2024 Resident 84 did not receive her tramadol 50mg at 5:00 p.m. During a review of Resident 84's controlled drug record, titled Antibiotic or Controlled Drug Record, dated 12/1/2024, the Antibiotic or Controlled Drug Record indicated to give one tablet of tramadol 50mg every six hours as needed for severe pain. The Antibiotic or Controlled Drug Record indicated tramadol 50mg was removed on 12/1/2024 at 12:00 p.m. During a review of Resident 84's Electronic Medication Administration Record ([eMAR]- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 12/1/2024, the eMAR indicated on 12/1/2024 Resident 84 did not receive her tramadol 50mg at 12:00 p.m. 555368 Page 14 of 24 555368 02/07/2025 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0697 Level of Harm - Minimal harm or potential for actual harm During an interview on 2/6/2025 at 12:45 p.m. with Resident 84, Resident 84 stated she had chronic pain (pain that persists for a prolonged period lasting beyond the normal healing time after an injury or illness) in her neck and when she requested for pain medication there was a delay and did not receive her pain medication. Resident 84 stated the delay in not receiving the pain medication mad her neck pain worse. Resident 84 stated the delay of not receiving her pain medication made her feel frustrated and upset. Residents Affected - Few During a concurrent interview and record review on 2/7/2025 at 1:01 p.m. with Licensed Vocational Nurse (LVN) 2, Resident 84's Antibiotic or Control Drug Record and eMAR, dated 11/30/2024 and 12/1/2024 was reviewed. The Antibiotic or Control Drug Record indicated on 11/30/2024 at 5:00 p.m. and 12/1/2024 at 12:00 p.m. tramadol 50mg was removed from medication cart. The eMAR indicated Resident 84 did not receive tramadol 50mg 11/30/2024 at 5:00 p.m. and 12/1/2024 at 12:00 p.m. LVN 2 stated the protocol is to remove the pain medication from the narcotic medication cart, sign on the Antibiotic or Control Drug Record log that the medication was removed. LVN 2 stated once the medication is removed from the narcotic cart the time and date should correspond with the eMAR. LVN 2 stated the eMAR does not show the pain medication given nor was documented that it was given to Resident 84. LVN 2 stated not given the pain medication to Resident 84 could cause her to feel not happy and feel worse. During an interview on 2/7/2025 at 1:22 p.m. with Minimum Data Set (MDS) Nurse, Resident 84's Antibiotic or Control Drug Record and eMAR, dated 11/30/2024 and 12/1/2024 was reviewed. The Antibiotic or Control Drug Record indicated on 11/30/2024 at 5:00 p.m. and 12/1/2024 at 12:00 p.m. tramadol 50mg was removed from medication cart. The eMAR indicated Resident 84 did not receive tramadol 50mg 11/30/2024 at 5:00 p.m. and 12/1/2024 at 12:00 p.m. The MDS Nurse stated it does not look like the tramadol pain medication was given to Resident 84. The MDS Nurse stated it could make Resident 84 agitated and increase her discomfort. During a review of facility's policy and procedure (P&P) titled, Charge Nurse, date unknown, the P&P indicated ensures that policies and procedures are complied with by nursing personnel assigned. The P&P indicated the charge nurse prepares and administers medications as per physicians' orders. During a review of facility's policy and procedure (P&P) titled, Medication Administration, dated 11/2017, the P&P indicated review MAR to identify medication to be administered. The P&P indicated to administer with 60 minutes prior to or after scheduled times unless otherwise ordered by physician. The P&P indicated sign MAR after medication administration. 555368 Page 15 of 24 555368 02/07/2025 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Ensure one of four sampled residents (Resident 39) had an assessment and order for the use of siderails. This deficient practice had the potential to result in inappropriate use of siderails for Resident 39 and could lead to injuries. Findings: During an observation on 2/4/2025 at 9:20 a.m., Resident 39 was resting in bed with 1 siderail up on each side of him. During a review of Resident 39's admission Record, it indicated Resident 39 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity) and encephalopathy (a medical condition that affects the brain's function). During a review of Resident 39's Order Summary Report, there were no orders seen for the use of siderails. During an interview on 2/6/2025 at 1:25 p.m. with Registered Nurse (RN) 1, RN 1 stated residents who should have or want to have siderails need to have an Interdisciplinary Team (IDT) Meeting to determine if it is appropriate for them to use. RN 1 stated residents who are not fully alert and able to follow safety directions should not have siderails. If it is determined that siderails are appropriate for the resident, they would call the physician to put in an order. During an interview on 2/6/2025 at 2:15 p.m. with the Minimum Data Set Nurse (MDSN), MDSN stated an IDT meeting would be held to determine if it is safe for the resident to have siderails. MDSN stated Resident 39 did not have an assessment done or an order for the use of siderails. MDSN stated sometimes siderails are not appropriate like if they are not alert enough to follow directions or if they have unsteady gait or if they were not able to use it at all. An order for siderails is also needed so the physicians and the care team are all on the same page. During a review of the facility's policy and procedure (P&P), undated, it indicated an assessment of the resident's symptoms and the reason for using siderails would be conducted prior to use and would be documented in the residents' record. 555368 Page 16 of 24 555368 02/07/2025 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 failed to: 1. Discard a bottle of expired cranberry extract in the medication cart. 2. Label a bottle of opened docusate liquid with the open date. This deficient practice had the potential for the residents to receive ineffective medication dosages. Findings: During an observation on [DATE] at 11:30 a.m., of medication cart #3 at nurses station #3, a bottle of cranberry juice extract had an expiration date of 1/2025 and a bottle of opened docusate sodium liquid did not have an open date was found. During an interview on [DATE] at 11:54 a.m. with the Treatment Nurse (TN), the RN stated the cranberry juice extract was expired and should have been disposed of. If left in the cart, there is potential for the resident to receive the expired medication, and that medication could have not been as effective. TN also stated the bottle of opened docusate liquid should have an open date on it, if not, the nurses would not have known when it was opened. During a review of the facility's policy and procedure (P&P), titled Storage of Medications, undated, it indicated the facility should not use discontinued, outdated or deteriorated drugs, and all such drugs should be returned to the pharmacy or destroyed. It also indicated that nursing staff are responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 555368 Page 17 of 24 555368 02/07/2025 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. 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 - Few 1. Ensure one out of four sampled residents (Resident 84) food items stored in Resident 84's room were not dated and labeled. This deficient practice of not having food items dated and labeled had the potential to for Resident 84 to cause a stomach infection (an inflammation of the stomach and intestines caused by bacteria). Findings: During a review of Resident 84's admission Record (Face Sheet), the Face Sheet indicated Resident 84 was admitted to the facility on [DATE]. Resident 84's diagnoses included cervicalgia (neck pain or discomfort in the upper spine), idiopathic neuropathy (a condition where nerve damage occurs with no identifiable cause), and anxiety (a feeling of apprehension or dread that can be caused by a real or perceived threat). During a review of Resident 84's History and Physical (H&P), dated 11/24/2024, the H&P indicated Resident 84 had the capacity to understand and make decisions. During a review of Resident 84's Minimum Data Set ([MDS] a mandated assessment tool), dated 12/28/2024 the MDS indicated, Resident 84's cognition (ability to learn, reason, remember, understand, and make decisions) he was able to understand. The MDS indicated Resident 84 was independent with personal hygiene, dressing, and eating. The MDS indicated Resident 84 was on a therapeutic diet (a meal plan that helps patients manage health conditions). During an observation on 2/4/2025 in Resident 84's room there were 1 liter ([l]-a metric unit of measurement used to calculate volume) of coke-cola bottle, a large bag of opened ruffles potato chips, and an open jar of Cheez Whiz were not dated or labeled. During an interview on 2/4/2025 at 12:53 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated when Resident 84 brought in outside food (food brought into a healthcare facility by a patient or visitor) the food items were to be dated and labeled by the staff. LVN 3 stated the food items should not bed stored in the resident room for no more than three days. LVN 3 stated keeping the food items in Resident 84's room for more than three days had the potential for the resident to have stomach problems such as diarrhea (having loose or watery stools more than three times a day). During a concurrent observation and interview on 2/5/2025 at 3:24 p.m. with Certified Nursing Assistant (CNA) 2, in Resident 84's room, Resident 84 had 1 liter ([l]-a metric unit of measurement used to calculate volume) of coke-cola bottle, a large bag of opened ruffles potato chips, and an open jar of Cheez Whiz were not dated or labeled. CNA 2 stated food items in the resident's rooms were to be dated. CNA 2 stated once the food item is opened the staff is to keep track of the date and throw the food item once its pass three days. CNA 2 stated if the food items in Resident 84's room she could get a stomach illness. During a review of facility's policy and procedure (P&P) titled, Use and Storage of Food Brought in 555368 Page 18 of 24 555368 02/07/2025 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few by Family or Visitors, date unknown, the P&P indicated it is the right of the residents of this facility to have food [NAME] in by family or other visitors, however, the food must be handled in a way to ensure the safety of the resident. The P&P indicated all food items must be labeled with content and dated and must be consumed within three days. The P&P indicated if food items were not consumed within three days, food will be thrown away by facility staff. The P&P indicated all food items brought in to the facility must be kept in the resident room inside a lock tight container. 555368 Page 19 of 24 555368 02/07/2025 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one of four sampled residents (Resident 22), by failing to: 1. Document the correct information on the when the resident transferred to a different facility. This deficient practice had the potential to result in confusion and incomplete assessment of the resident's needs and could lead to a lack of or delay in delivery of necessary care or services to Resident 22. Findings: During a review of Resident 22's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission record indicated, Resident 22 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 22's diagnoses included chronic kidney disease ([CKD], condition which the kidneys are damaged and cannot filter blood as well as they should), schizophrenia (a mental illness that is characterized by disturbances in thought), and anxiety disorder (persistent and excessive worry that interferes with daily activities). During a review of Resident 22's History and Physical (H&P), dated 11/24/24, the H&P indicated Resident 22 did not have the capacity to understand and make decisions. A review of Resident 22's Minimum Data Set (MDS - a federally mandated resident assessment tool)), dated 11/26/24, indicated Resident 22 was assessed to comprehend (the action or capability of understanding something) most conversation. The MDS indicated Resident 22 required supervision or touching assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as oral hygiene, showering, sit to stand, chair/bed-to-chair transfer, and toilet transfer. During a concurrent interview and record review on 2/4/25 at 9:06 a.m. with Director of Staff Development (DSD), Resident 22's SNF/NF to Hospital Transfer Form (Transfer form) dated 2/3/25, the transfer form Resident 22 was sent to Los Angeles Downtown Medical Center on 11/20/24 [NAME] to behavior symptoms. The transfer form indicated most current vital signs were dated blood pressure 124/72 on 1/25/25, heart rate 78 on 1/19/25, respiratory rate 16 on 1/19/25, temperature 97.2 degrees Fahrenheit on 1/19/25 and oxygen saturation level 97 percent on 1/19/25. The transfer form indicated report called in to receiving facility on 2/3/25 at 4:50 p.m. DSD stated the Resident 22 wanted to go to the facility she was before, so we arranged her transfer, Resident 22 was transferred on 2/3/25. DSD stated the transfer form was not filled out correctly, the vitals should have been from the day she left the facility. DSD stated it is very important to document correct, it was a guide to know what is happing with the resident. DSD stated if the documentation was not correct, it could affect the type of care the resident receives. DSD stated this can potentially harm the resident. During an interview on 2/7/25 at 10:13 a.m. with Registered Nurse (RN) 2, RN 2 stated Resident 22 was transferred to another facility that she wanted to go to. RN 2 stated I forgot to updated the transfer form with the correct information. RN2 stated documentation not done correctly may affect the resident in the correct care given to resident. 555368 Page 20 of 24 555368 02/07/2025 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0842 Level of Harm - Minimal harm or potential for actual harm During an interview on 2/7/25 at 10:28 a.m. with the Director of Nursing (DON), the DON stated documenting correctly was important, it was how we know the condition of the resident. DON stated when a resident is being transferred out of our facility it was important to document correctly the vitals, mode of transportation, where resident was going. DON stated if documentation was not done correctly there would be no way to know if the resident was stable, where the resident went to, who picked them up. Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, (undated), the P&P indicated, all services provided to the resident, or any changes in the resident's medial or mental condition, shall be documented in the resident's medical record. 555368 Page 21 of 24 555368 02/07/2025 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 failed to: Residents Affected - Some 1. Ensure two out of four sampled residents (Resident 57): nasal cannula and humidifiers (a medical device that provides supplemental oxygen to a patient through their nose) were dated, labeled and (Resident 36) GT feeding was changed per physcian orders. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for residents. Findings: a. During a review of Resident 57's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 57 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 57's diagnoses included chronic obstructive pulmonary disease ([COPD]- a chronic lung disease causing difficulty in breathing), respiratory failure (when the body's respiratory system is unable to exchange oxygen and carbon dioxide properly), and chronic heart failure (a condition where the heart can't pump blood efficiently). During a review of Resident 57's History and Physical (H&P), dated 12/20/2024, the H&P indicated, Resident 57 did not have the capacity to understand and make decisions. During a review of Resident 57's Minimum Data Set ([MDS] a resident assessment tool), dated 1/15/2025, the MDS indicated Resident 57's cognition (ability to learn, reason, remember, understand, and make decisions) was moderately impaired. The MDS indicated Resident 57 was substantial assistance on staff for showering, dressing, and personal hygiene. The MDS indicated Resident 57 health condition included shortness of breath (trouble breathing) with exertion (walking, bathing, transferring, and when lying flat. During an observation on 2/4/2025 at 9:57 a.m. in Resident 57's room, there a humidifier attached to a concentrator (it takes air from your surroundings, extract oxygen and filter it into purified oxygen for you to breathe) and a nasal cannula connected to the humidifier. The humidifier was dated 12/20/2024 and the nasal cannula was not dated and labeled. During a review of Resident 57's physician orders titled, Order Summary Report, dated 12/10/2024, the physician orders indicated oxygen at two liters ([L] -a metric unit of measurement used to calculate volumes) per minute continuously every shift for shortness of breath and wheezing (a high-pitched whistling sound that indicates a person may be having trouble breathing). During a concurrent observation and interview on 2/5/2025 at 12:08 p.m. with Licensed Vocational Nurse (LVN) 3 in Resident 57's room, Resident 57 had a humidifier attached to a concentrator dated 12/20/2024 and the nasal cannula was not dated and labeled. LVN 3 stated the humidifier should have been changed every two weeks. LVN 3 stated the humidifier provides moisture to the resident and if it was not changed every two weeks it could cause a respiratory infection. LVN 3 stated the nasal cannula needed to be changed every two weeks to prevent respiratory infection. 555368 Page 22 of 24 555368 02/07/2025 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0880 Level of Harm - Minimal harm or potential for actual harm During an interview on 2/5/2025 at 12:32 p.m. with Minimum Data Set (MDS) Nurse, the MDS Nurse stated the humidifier and nasal cannula tubing should be changed weekly. The MDS Nurse stated the nasal cannula could get clogged with mucus dryness, condensation (water collects) buildup in the tubing. The MDS Nurse stated not changing the humidifier and the nasal cannula tubing weekly could cause Resident 57's COPD to exacerbate (to make a disease or its symptoms worse). Residents Affected - Some During a review of facility's policy and procedure (P&P) titled, Oxygen Administration, date unknown, the P&P indicated the purpose of this procedure is to provide guidelines for safe oxygen administration. The P&P indicated the following equipment and supplies a nasal cannula and humidifier bottle will be necessary when performing this procedure. The P&P did not indicate issues regarding infection control. During a review of facility's policy and procedure (P&P) titled, Oxygen Concentrator, date unknown, the P&P indicated to administer oxygen for the treatment of certain disease or conditions. The P&P indicated the care of the concentrator were to change tubing weekly, change humidifier every seven days or as needed, and change nebulizer tubing every seven days. b. During an observation on 2/4/2025 at 10:28 am at Resident 36's bedside, a 50.7-ounce container of Jevity 1.2 cal enteral nutrition was hanging from an IV pole dated 2/2/2025 5am. The container had 200 mL's of formula remaining. During a review of Resident 36's admission Record, the admission record indicated the facility re-admitted on [DATE] with diagnoses that included dysphagia (swallowing difficulty), ileus (a condition where the normal movement of food and waste through the gut is impaired), and cerebrovascular disease (a group of conditions that affect the blood vessels in the brain and spinal cord). During a review of the Minimum Data Set (MDS - a resident assessment tool), the MDS indicated Resident 36 usually had the ability to express ideas and wants and sometimes had the ability to understand others. The MDS also indicated Resident 36 was dependent (helper does all the effort) in all functional abilities. During a review of Resident 36's Order Summary Report, dated 2/3/2025, the report indicated Enteral Feed Order every shift Jevity 1.2 @ 40cc x 20 hours to yield 800cc/1200 kcal in 24 hours via continuous feeding pump. Turn feeding off at 10am or till dose is completed. During a review of the manufacturers product information titled Jevity 1.2 Cal, the document indicated to hang for no more than 24 hours and that all medical foods, regardless of type of administration system, require careful handling because they can support microbial (bacteria) growth. During a concurrent interview and record review on 2/7/2025 at 9:18 am with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 36's enteral nutrition should be changed everyday because it is no longer fresh. It is like food being left out and could cause diarrhea, constipation, or vomiting. A review of a picture taken on 2/4/2025 at 10:29 am at Resident 36's bedside, of the Jevity container dated 2/2/2025 5am without a nurse's signature or initials, LVN 2 stated the container hanging there should be dated 2/3/2025 if it was changed every twenty-four hours as ordered. During a review of the facility's policy and procedure (P&P) titled Enteral Nutrition, undated, the P&P indicated, Adequate nutritional support through enteral feeding will be provided to residents as ordered. 555368 Page 23 of 24 555368 02/07/2025 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0912 Level of Harm - Potential for minimal harm Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **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. Ensure six out of forty-seven rooms met the requirement of the minimum 80 square footage ([sq ft] - a unit of an area measurement equal to a square measuring one foot on each side) per room. This deficient practice to provide adequate space created the potential for adversely affecting the quality of life and safety who may had occupied rooms 22,24,26,27,28 and 29. Findings: During an observations and interviews, on 2/7/2025 at 2:30 p.m. with Maintenance Supervisor, the Maintenance Supervisor confirmed the room measurements for rooms 22,24,26,27,28, and 29. Room Number Floor per square footage Beds per room 22 229.13 sq ft 3 24 229.13 sq ft 3 26 229.13 sq ft 3 27 227.5 sq ft 3 28 225.87 sq ft 3 29 225.87 sq ft 3 During an interview on 2/7/2025 at 2:38 p.m. with Administrator (ADM), the ADM stated the facility had a room waiver for a room variance. The ADM provided a copy of room wavier letter, dated 4/13/2024, the room waiver indicated rooms 22,24,26,27,28, and 29 had less than 80 square feet in multi-patient's rooms. During an interview on 2/7/2025 at 2:48 p.m. with Administrator (ADM), the ADM stated rooms 22, 26, 27, 28,29, had three residents occupied these rooms. The ADM stated room [ROOM NUMBER] had two residents. The ADM stated these rooms did not meet the 80 sq ft requirements. The ADM stated the residents who occupied the rooms with smaller square footage would have less space in the rooms. The ADM stated the less room residents have to walk around. The ADM stated this would affect the resident's safety and environment which would increase the resident's chances of having an accident. During a review of facility's policy and procedure (P&P) titled, Room Size and Occupancy, date unknown, the P&P indicated the facility ensures that all resident rooms meet the state and federal regulations regarding room size, occupancy limits, and space requirements to provide a safe, comfortable, and functional living environment. The P&P indicated shared rooms must provide at least 80 square feet per resident. 555368 Page 24 of 24