Health inspection·November 19, 2023

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. Based on observation, interview, and record review, the facility failed to promote one of three sampled resident's (Resident 4) dignity by failing to ensure Certified Nursing Assistant (CNA 1) was not standing over Resident 4 while assisting the resident with feeding. This deficient practice had the potential to affect the resident's sense of self-worth and self-esteem. Findings: A review of Resident 4's admission Record indicated the facility admitted the resident on 5/8/2023 with diagnoses including toxic encephalopathy (a disturbance of normal brain function) and dysphagia (difficulty swallowing). A review of Resident 4's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/12/2023, indicated the resident had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and was totally dependent on staff for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. During a concurrent observation and interview on 11/18/2023 at 12:31 p.m., observed Resident 4 awake in bed. Observed CNA 1 standing next to Resident 4's bed while assisting the resident with eating. Observed CNA 1 not at eye level with Resident 4. Observed a fold-up chair behind Resident 4's bed. When asked if she had been in-serviced (training, as in special courses, workshops, etc., given to employees in connection with their work to help them develop skills) by the facility on how to assist residents with feeding, CNA 1 stated yes, she had been in-serviced before and knew she should be sitting at eye level with residents while feeding them. CNA 1 stated she had forgotten to do so. During an interview on 11/19/2023 at 2:32 p.m., with the Director of Staff Development (DSD), the DSD stated when she in-services staff about how to feed residents, she tells them they should be seated at eye level next to the resident. The DSD stated it was important for staff to be at eye level with residents while assisting them with eating so they can watch to make sure residents are not having difficulty swallowing. The DSD stated it was also important to maintain residents' sense of dignity. The DSD stated residents can possibly feel rushed if staff stand over them while assisting them with eating. A review of the facility's policy and procedure titled, Dignity and Respect, last revised on 3/2023, indicated each resident shall be cared for in a manner that promotes and enhances quality of life, Page 1 of 21 555519 555519 11/19/2023 The Care Center on Hazeltine, LLC 6835 Hazeltine Ave. Van Nuys, CA 91405

F 0550 Level of Harm - Minimal harm or potential for actual harm dignity, respect, and individuality. The intent of the policy is to provide staff with guidelines to ensure residents are treated with kindness, respect, and dignity. The facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity .Residents shall be treated with dignity and respect at all times. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. Residents Affected - Few 555519 Page 2 of 21 555519 11/19/2023 The Care Center on Hazeltine, LLC 6835 Hazeltine Ave. Van Nuys, CA 91405

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 ensure there was documented evidence that education about an advanced directive (written document that indicated a person's wishes regarding medical treatment if that person is no longer able to communicate) was provided for one of three residents (Resident 17) investigated under the Advance Directives care area. This deficient practice violated Resident 17's and/or their representatives' right to be fully informed of the option to formulate an advance directive and had the potential to cause conflict due to lack of communication regarding Residents 17's wishes about their medical treatment. Findings: A review of Resident 17's admission Record indicated the resident was admitted on [DATE] with diagnosis the included fibromyalgia (a chronic [long-lasting] disorder that causes pain and tenderness throughout the body), encounter to palliative care (specialized medical care for people TV living with a serious illness), muscle weakness, and moderate calorie malnutrition (lack of sufficient nutrients in the body). A review of Resident 17's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 10/13/2023 indicated the resident's cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was severely impaired. The MDS indicated that Resident 17 was dependent with eating, toileting, and personal hygiene. During a concurrent interview and record review on 11/19/2023 at 2:47 p.m., with the Social Services Director (SSD), reviewed Resident 17's medical record in regards to advance directive documentation. The SSD stated that upon admission, she will ask the resident or resident's responsible party if the resident has an advanced directive. If the resident does not have an advance directive, the SSD stated they she will discuss and educate the resident and their responsible party of advanced directives and will assist in formulating an advanced directive. The SSD stated that she was not able to find documented evidence that an advanced directive was discussed and that education about an advanced directive was provided to Resident 17 and their responsible party. When asked about the importance of informing residents and their responsible party about advanced directives, the SSD stated it is important because it is the resident's right to form an advanced directive. A review of the facility's policy and procedure titled, Advance Directives, reviewed date 9/25/2023, indicated patients have the right to make decisions concerning their care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives as permitted under state statutory and case law .Staff will document in the patient's medical record whether the adult patient has executed any advance directives .All staff involved in the patient's care will be informed of the patient's advance directive .If the patient does not have any advance directives but would like additional information, such information will be provided by staff. 555519 Page 3 of 21 555519 11/19/2023 The Care Center on Hazeltine, LLC 6835 Hazeltine Ave. Van Nuys, CA 91405

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview, and record review the facility failed to provide a safe, clean comfortable and homelike environment for one of one sampled resident (Resident 35) by failing to repair peeling paint in the restroom door and failing to ensure that there was no hole in the drywall above Resident 35's bed. This deficient practice had the potential to negatively affect the residents' comfort and well-being. Findings: A review of the Resident 35's admission Record indicated the facility admitted the resident on 11/19/2022 with diagnoses that included muscle weakness (a decrease in muscle strength), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and dehydration (an abnormal loss of water from the body). A review of Resident 35's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 8/26/2023 indicated the resident had clear speech, usually makes self-understood, and usually understand others. The MDS indicated that the resident required extensive assistance with bed mobility, dressing, and personal hygiene. During an observation on 11/18/2023 at 8:52 a.m. inside Resident 35's room, observed Resident 35 sleeping. Upon closer inspection of the room, observed a two by one inch irregular hole in the wall close to Resident 35's headboard and peeling paint on the restroom door. During an interview on 11/19/23 at 2:26 p.m., the Director of Nursing (DON) stated that resident`s rooms should have no holes in the wall and no peeling paint in any part of the room. The DON stated that she was made aware that Resident 35`s room had a hole in the wall, and peeling paints in the toilet area. DON stated she verified by observing firsthand the hole in the wall and the peeling paint inside Resident 35's room. The DON stated that if a resident's surrounding is not clean or presentable, it can affect the resident`s dignity. A review of the facility`s policy and procedure titled, Homelike Environment, last revised on 3/2023, indicated that the facility strives to provide a personalized, homelike environment which recognizes the individuality and autonomy of the resident it is the responsibility of all facility staff to create a homelike environment and promptly address any cleaning needs . 555519 Page 4 of 21 555519 11/19/2023 The Care Center on Hazeltine, LLC 6835 Hazeltine Ave. Van Nuys, CA 91405

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a written course of action that helps a patient achieve outcomes that improve their quality of life) with measurable goals and objectives including person-centered interventions addressing a resident's hearing loss problem for one of one sampled resident (Resident 44) investigated under the care area Communication-Sensory. This deficient practice had the potential to negatively affect the delivery of care and services to Resident 44. Findings: A review of Resident 44's admission Record indicated the facility admitted the resident on 6/10/2022, with diagnoses that included hypertension (high blood pressure), muscle weakness, and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Resident 44's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 6/15/2023, indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making were intact and required limited assistance for bed mobility, dressing, toilet use, and personal hygiene. The MDS indicated Resident 44 had minimal difficulty with hearing. A review of Resident 44's Ear, Nose and Throat (ENT) consult dated 9/12/2023 indicated a reason for the consult was that of hearing loss. The ENT consultation indicated that the resident was referred for an audiogram (a chart that shows the results of a hearing test). During a resident council interview on 11/18/23 at 9:58 a.m., observed Resident 44 talking loud and off topic. When Resident 44 was asked a question, another resident attendee seated beside the resident, would repeat the statement and would frequently repeat what was discussed during the interview. When Resident 44 was asked aloud if he can hear, the resident stated that he has a hearing problem and does not have a hearing aid. During a concurrent interview and record review on 11/19/2023 at 1:38 p.m., with the Director of Nursing (DON), reviewed Resident 44's MDS dated [DATE], wherein the resident was assessed to have minimal difficulty with hearing. The DON stated that Resident 44's hearing loss problem can affect his dignity and his ability to communicate, which could lead to frustration. The DON stated that when the Resident 44 was assessed with having minimal difficulty with hearing on 6/15/2023, the facility should have developed a care plan to put in place interventions to address his communication deficit. A review of the facility's policy and procedure titled, Treatment/Devices to Maintain Hearing/Vision, last revised on 3/2023, indicated The facility provides care and services to ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities .the intent of the regulation is to ensure the facility assists the resident in gaining access to vision and hearing services by making appointments and arranging for transportation . 555519 Page 5 of 21 555519 11/19/2023 The Care Center on Hazeltine, LLC 6835 Hazeltine Ave. Van Nuys, CA 91405

F 0656 Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure titled, Comprehensive Care Plans-Timing, last revised on 3/2023, indicated Each resident shall have a person-centered, comprehensive care plan, developed, reviewed, and revised by the facility`s interdisciplinary team including the resident and resident representative, if applicable . Residents Affected - Few 555519 Page 6 of 21 555519 11/19/2023 The Care Center on Hazeltine, LLC 6835 Hazeltine Ave. Van Nuys, CA 91405

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure one of one sampled (Resident 44) resident investigated under the care area communication and sensory was provided a medical hearing consult promptly (the resident had been waiting approximately two months) after the resident was assessed to have a hearing loss problem. Residents Affected - Few This deficient practice resulted in a delay in delivering the necessary care and services to maintain the resident`s ability to communicate. Findings: A review of Resident 44's admission Record indicated the facility admitted the resident on 06/10/2022 with diagnoses that included hypertension (high blood pressure), muscle weakness, and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Resident 44`s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 06/15/2023, indicated the resident`s cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making were intact and the resident required limited assistance for bed mobility, dressing, toilet use, and personal hygiene. The MDS indicated that the resident had minimal difficulty with hearing. A review of Resident 44`s Ear, Nose and Throat (ENT) consult dated 9/12/2023 indicated a reason for consult was for hearing loss. The ENT consultation indicated that the resident was referred for audiogram (a chart that shows the results of a hearing test). During a resident council interview on at 11/18/23 09:58 a.m., observed Resident 44 talking loudly. When Resident 44 was asked aloud if he can hear, the resident stated that he has a hearing problem and does not have a hearing aid. During an interview on 11/19/2023 at 1:38 p.m., with the Director of Nursing (DON), the DON stated that Resident 44 has an upcoming appointment with the hearing center. The DON was not able to explain why there was such a delay in obtaining Resident 44's hearing assessment as there was an order to complete an audiogram on 9/12/2023. The DON stated that a resident`s hearing loss problem can affect their dignity and their ability to communicate which could lead to frustration. A review of the facility`s policy and procedure title Treatment/Devices to Maintain Hearing/Vision, last revised on March 2023, indicated that the facility provides care and services to ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities .the intent of the regulation is to ensure the facility assists the resident in gaining access to vision and hearing services by making appointments and arranging for transportation . 555519 Page 7 of 21 555519 11/19/2023 The Care Center on Hazeltine, LLC 6835 Hazeltine Ave. Van Nuys, CA 91405

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. A review of Resident 49's admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnoses that included seizures (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations or states of awareness), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning). Residents Affected - Some A review of Resident 49's MDS dated [DATE], indicated that Resident 49's cognitive skills for daily decision making was severely impaired. The MDS also indicated that Resident 49 required extensive assistance with bed mobility, dressing, and personal hygiene. A review of Resident 49's Care Plan titled, ADL: Resident 49 requires assistance in personal hygiene indicated an intervention to assist with maintaining good personal hygiene every shift and as needed. During an observation on 11/18/2023 at 11:39 a.m., observed Resident 49 with long and dirty fingernails. During a concurrent observation and interview on 11/18/2023 at 11:46 a.m., with Certified Nursing Assistant 1 (CNA 1), observed Resident 49's nails and CNA 1 described Resident 49's fingernails as long and dirty. CNA 1 stated that residents' nails should not be long and should be kept short. CNA 1 continued to state that she will go cut Resident 49's nails. A review of the facility`s policy and procedure titled, ADL Care Provided for Dependent Residents, last revised on 3/2023, indicated, A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal hygiene. Based on observation, interview and record review, the facility failed to ensure a resident's fingernails was not dirty and has no black substances under the tip of the nails for three of three sampled residents (Resident 10, 43, and 49) investigated under activities of daily living. This deficient practice had the potential to result in a negative impact on the resident's self- esteem due to an unkempt appearance. Findings: a. A review of Resident 10's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including muscle weakness, chronic obstructive pulmonary disease (refers to a group of diseases that cause airflow blockage and breathing-related problems), and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). A review of Resident 10's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 10/31/2023, indicated the resident had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) with skills for daily decision making and required assistance for bed mobility, dressing, toilet use, and 555519 Page 8 of 21 555519 11/19/2023 The Care Center on Hazeltine, LLC 6835 Hazeltine Ave. Van Nuys, CA 91405

F 0677 personal hygiene. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview 11/18/23 at 9:36 a.m., with Registered Nurse 2 (RN 2), observed Resident 10 in bed with long and dirty fingernails on both hands. RN 2 verified the observation and stated that Resident 10's fingernails were long and had black substances under the tip of the nails and required trimming. Residents Affected - Some During an interview on 11/19/2023 at 9:09 a.m., with the Director of Nursing (DON), the DON stated that grooming includes bed bath, shower, shaving facial hair, brushing the resident's teeth and fingernail trimming. The DON stated that proper grooming promotes the resident's dignity. A review of the facility's policy and procedure titled, Activities of Daily Living (ADL- activities related to personal care) Care Provided for Dependent Residents, last revised on 3/2023, indicated A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal hygiene. b. A review of Resident 43's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included muscle weakness, chronic obstructive pulmonary disease (refers to a group of diseases that cause airflow blockage and breathing-related problems), and history of falling. A review of Resident 43's MDS dated [DATE], indicated the resident had moderately impaired cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making and required assistance for bed mobility, dressing, toilet use, and personal hygiene. During a concurrent observation and interview on 11/18/2023 at 8:52 a.m., with RN 2, observed Resident 43 laying in bed, awake and able to respond when interviewed. Observed Resident 43's fingernails to be long, untrimmed and with black substances under the tip of the nails. Resident 43 stated that he likes his fingernails to be short. RN 2 verified the observation and stated that Resident 43's fingernails were long and had black substances under the tip of the nails. RN 2 stated that nursing assistants provide bedside care including trimming the residents' nails if they are not diabetic (person with diabetes [a condition that affects the way the body processes blood sugar]). RN 2 stated that untrimmed fingernails can potentially cause skin breakdown if residents were to scratch themselves. RN 2 stated that Resident 43 eats with his hands and if his nails were dirty, it may place the resident at risk for infection. A review of the facility's policy and procedure titled, ADL Care Provided for Dependent Residents, last revised on 3/2023, indicated, A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal hygiene. 555519 Page 9 of 21 555519 11/19/2023 The Care Center on Hazeltine, LLC 6835 Hazeltine Ave. Van Nuys, CA 91405

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure one of one sampled residents (Resident 11) had on bilateral (both sides) heel protectors (device that can help prevent and treat heel pressure sores), as ordered by the physician, investigated for pressure ulcer/injury (a skin injury that occurs when an area of skin is under constant or prolonged pressure). Residents Affected - Few This deficient practice placed the resident at risk of discomfort and development of new pressure ulcers. Findings: A review of Resident 11's admission Record indicated the facility originally admitted the resident on 7/31/2015 and readmitted the resident on 2/7/2021 with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 11's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/12/2023, indicated the resident had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and was totally dependent on staff for bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. A review of Resident 11's physician's orders, dated 4/30/2023, indicated to apply bilateral feet heel protectors every shift for skin management. A review of Resident 11's care plan (a written document that details a patient's needs, goals, and treatments), initiated on 12/26/2022, indicated the resident has a higher risk/potential for pressure ulcer development related to disease process. Resident has a history of ulcers, immobility, and incontinence (loss of bowel or bladder control). The goal indicated that the resident will have intact skin, free of redness, blisters, or discoloration by/through the review date. One of the interventions listed was to apply bilateral feet protectors as ordered. During a concurrent observation and interview on 11/19/2023 at 3:37 p.m., with Registered Nurse 1 (RN 1), observed Resident 11 awake in bed. Observed both of Resident 11's heels on the bed and without heel protectors on. RN 1 confirmed by stating Resident 11 did not have bilateral heel protectors on and stated the resident should have had heel protectors on. During an interview on 11/19/2023 at 4:31 p.m., with the Director of Nursing (DON), the DON stated heel protectors were important to prevent the development of skin breakdown. The DON stated if staff did not apply the resident's heel protectors as ordered, it increases the resident's risk of developing a pressure ulcer. A review of the facility's policy and procedure titled, Skin Assessment, last reviewed on 3/2023, indicated the policy is intended to provide staff guidelines to reduce the potential for residents to develop pressure ulcers/injuries (PU/PIs) unless clinically unavoidable and that the facility provides care and services consistent with professional standards of practice to: -Promote the prevention of pressure ulcer/injury development; 555519 Page 10 of 21 555519 11/19/2023 The Care Center on Hazeltine, LLC 6835 Hazeltine Ave. Van Nuys, CA 91405

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few -Promote the healing of existing pressure ulcers/injuries (including prevention of infection to the extent possible); and -Prevent development of additional pressure ulcer/injury. -The sacrum (a triangular bone at the base of the spine, above the tailbone) and heels should be inspected for pressure related concerns and are the areas of greatest vulnerability. 555519 Page 11 of 21 555519 11/19/2023 The Care Center on Hazeltine, LLC 6835 Hazeltine Ave. Van Nuys, CA 91405

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Ensure the attending physician assess and documented in the resident`s medical record the rationale for extending Ativan (medication is used to treat anxiety [(intense, excessive, and persistent worry and fear about everyday situations]) for 30 additional days for one of two sampled residents (Resident 47) reviewed for Unnecessary Medications. 2. Provide non-pharmacological interventions (health interventions that are not primarily based on medication) to Resident 11 prior to administering as needed (prn) Ativan on multiple dates for one (Resident 11) of five sampled residents investigated for unnecessary medications. These deficient practices had the potential to result in unnecessary medications and had the potential to result in adverse reaction or impairment in the resident's mental or physical condition. Findings: 1. A review of Resident 47's admission Record indicated the facility admitted the resident on 10/20/2023, with diagnoses that included encephalopathy (any disease that affects the whole brain and alters its structure or how it works, and causes changes in mental function), hypertension (high blood pressure), and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A review of Resident 47`s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 10/26/2023, indicated the resident had moderately impaired cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making and required assistance for bed mobility, dressing, toilet use, and personal hygiene. A review of Resident 47`s order for Ativan, dated 10/20/23, indicated to give one (1) tablet 0.5 milligram (mg-unit of measure) by mouth every six hours as needed for anxiety for 14 days. A review of Resident 47`s order for Ativan, dated 11/5/2023, indicated to give one (1) tablet 0.5 mg by mouth every six hours as needed for anxiety for 30 days. During a concurrent interview and record review with the Director of Nursing (DON) on 11/19/2023, reviewed Resident 47`s physician`s progress notes from to 11/19/2023. The DON stated that there was no documented evidence by the physician regarding the rationale for extending Resident 47's order for Ativan for another 30 days. The DON stated that a resident assessment and evaluation is required if a psychotropic medication (medications that affect the mind, emotions, and behavior) is extended. The DON stated that the physician would be able to determine the risks and benefits of extending or discontinuing a psychotropic medication for a resident during the assessment. The DON stated that Ativan`s side effects include dizziness and sedation which can potentially placed the resident at risk 555519 Page 12 of 21 555519 11/19/2023 The Care Center on Hazeltine, LLC 6835 Hazeltine Ave. Van Nuys, CA 91405

F 0758 for fall and injury. Level of Harm - Minimal harm or potential for actual harm A review of the facility`s policy and procedure titled, Dignity and Respect Psychoactive Medications, last revised on 3/2023, indicated, When reducing or eliminating the use of the medication may be contraindicated, the clinical record shall reflect the rational for the continued administration of the medication. Residents Affected - Some 2. A review of Resident 11's admission Record indicated the facility originally admitted the resident on 7/31/2015 and readmitted the resident on 2/7/2021 with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), depression (a serious mental illness that can cause a persistent feeling of sadness and loss of interest), schizophrenia, psychosis (a mental disorder characterized by a disconnection from reality), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and post-traumatic stress disorder (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). A review of Resident 11's MDS, dated [DATE], indicated the resident had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and was totally dependent on staff for bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. A review of Resident 11's physician's order dated 11/5/2023, indicated an order for Ativan 0.5 mg one tab by mouth (PO) every eight (8) hours as needed for anxiety manifested by inconsolable (unable to be comforted) screaming/yelling for 90 days. A review of Resident 11's care plan (a written document that details a patient's needs, goals, and treatment), initiated on 12/26/2022, indicated the resident was on Ativan related to anxiety manifested by inconsolable screaming and yelling. The goal indicated the resident will have no adverse side effects from medication use. Among some of the interventions listed was to use non-pharmacological approaches: (1) Encourage to verbalize feelings (needs/concerns); (2) Encourage family to participate in care; (3) Encourage to attend daily activities; (4) Provide a quiet & calm environment with diversion like listening to music and watching television; (5) Teach resident relaxation techniques or deep breathing exercises; (6) Redirect & provide gentle reality orientation; (7) Other as needed. On 11/19/2023 at 1:34 p.m., during an interview with Registered Nurse 1 (RN 1), RN 1 stated that Resident 11 was receiving Ativan 0.5 mg, one tablet by mouth every eight hours as needed for anxiety manifested by inconsolable (unable to be comforted) screaming and yelling for 90 days, since 11/5/2023. On 11/19/2023 at 2 p.m., during a concurrent interview and record review, reviewed Resident 11's 11/2023 Medication Administration Record (MAR - a report detailing the drugs administered to a resident by a healthcare professional) with RN 1. RN 1 stated that on the following dates and times, Resident 11 received Ativan 0.5 mg but did not receive non-pharmacological interventions prior to medication administration: 11/1/2023 at 1:56 a.m. and 5:04 p.m. 11/4/2023 at 8:23 a.m. 555519 Page 13 of 21 555519 11/19/2023 The Care Center on Hazeltine, LLC 6835 Hazeltine Ave. Van Nuys, CA 91405

F 0758 11/5/2023 at 4:59 p.m. Level of Harm - Minimal harm or potential for actual harm 11/9/2023 at 7:52 p.m. 11/19/2023 at 11:15 a.m. Residents Affected - Some RN 1 stated it was important to attempt non-pharmacological interventions prior to administering psychotropic medications because the medications can cause residents to experience side effects. On 11/19/2023 at 4:33 p.m., during an interview, the DON stated it was important to try non-pharmacological interventions before giving residents psychotropic medications because, if the intervention is effective, then the risk of a residents experiencing side effects from psychotropic medications can be minimized. The DON stated some of the side effects residents can experience from psychotropic medications include sedation, dizziness, and extrapyramidal symptoms (increased motor tone, changes in the amount and velocity of movement, and involuntary motor activity). A review of the facility's policy and procedure titled, Non-Pharmacological Intervention Management, last reviewed on 3/2023, indicated the purpose of the policy was to provide staff with non-pharmacological interventions which support the resident to attain or maintain his or her highest practicable well-being. 555519 Page 14 of 21 555519 11/19/2023 The Care Center on Hazeltine, LLC 6835 Hazeltine Ave. Van Nuys, CA 91405

F 0761 Level of Harm - Minimal harm or potential for actual harm Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility: Residents Affected - Some 1. Failed to document temperatures for the medication refrigerator. 2. Failed to ensure a bottle of Bismuth Subsalicylate (medication used to treat diarrhea [loose, watery and possibly more-frequent bowel movements]) that was labeled open on 11/17/2020 (approximately three years ago) was discarded. 3. Failed to ensure a bottle of Milk of Magnesia (medication to treat an upset stomach) was labeled with its open date (the date at which a new medication is first opened). These deficient practices had the potential to compromise the therapeutic effectiveness medication. Findings: 1. During a concurrent interview and record review on 11/17/2023 at 5:53 p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 reviewed the facility's Medication Refrigerator temperature log for 10/2023 and 11/2023. LVN 1 stated that facility staff should document the temperature of the refrigerator at the start and the end of each shift. LVN 1 reviewed the Medication Refrigerator temperature log for 10/2023 and 11/2023 and stated that there was no documentation of refrigerator temperatures for the following dates: a. 10/31/2023 for the 3-11p.m. shift b. 11/17/2023 for the 7-3 p.m. shift. During an interview with the Director of Nursing (DON) on 11/19/2023 at 7:07 p.m., the DON stated that it is important to monitor and document refrigerator temperatures to ensure that medications stored inside the refrigerator keep its potency. The DON stated that the facility does not have a policy specific monitoring the medication refrigerator. A review of the facility's policy and procedure titled, Storage of Medications, review date 9/25/2023, indicated medications and biologicals are stored safely, secured, and properly .Medications requiring refrigeration or temperatures between 2° Celsius (° C, a measurement of temperature [36° Fahrenheit (°F, a measurement of temperature)]) and 8°C (46° F) are kept in a refrigerator with a thermometer to allow temperature monitoring. 2. During a concurrent observation and interview on 11/17/2023 at 5:56 p.m., observed Medication Cart 1 with LVN 1. Observed inside Medication Cart 1 was a bottle of Bismuth Subsalicylate with an open date of 11/17/2020. LVN 1 stated that the bottle of Bismuth Subsalicylate should have been discarded because it was opened three (3) years ago. LVN 1 stated that medications should be discarded approximately 30 days after their open date. During an interview with the DON on 11/19/2023 at 7:07 p.m., the DON stated that it is important to 555519 Page 15 of 21 555519 11/19/2023 The Care Center on Hazeltine, LLC 6835 Hazeltine Ave. Van Nuys, CA 91405

F 0761 label house supply bottles with their open dates to remind staff when to discard the medication bottle. Level of Harm - Minimal harm or potential for actual harm 3. During a concurrent observation and interview on 11/17/2023 at 5:56 p.m., observed Medication Cart 1 with LVN 1. Observed inside Medication Cart 1 was an open bottle of Milk of Magnesia without an open date documented. LVN 1 stated that the medication bottle of Milk of Magnesia was open however it did not have an open date written on the bottle. LVN 1 stated that house supply (over the counter medications that can be used for multiple residents) liquid medications should be disposed after 30 days of opening the bottle for residents' safety. Residents Affected - Some During an interview with the DON on 11/19/2023 at 7:07 p.m., the DON stated the DON stated that it is important to label house supply medication bottles with their open dates to remind staff when to discard the medication bottle. When asked for the facility policy on labeling house medication bottles with the open dates, the DON stated that the facility does not have a policy specific on labeling house medication bottles with their open date. A review of the facility's policy titled Medication Label, review date 9/25/2023, indicated staff will assure that the resident medications are appropriately labeled. 555519 Page 16 of 21 555519 11/19/2023 The Care Center on Hazeltine, LLC 6835 Hazeltine Ave. Van Nuys, CA 91405

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to implement infection control practices by: Residents Affected - Some 1. Failing to ensure one of three sampled staff (Maintenance Assistant [MA]) did not wear gloves while walking in the facility's hallway. 2. Failing to ensure one of three sampled staff (Certified Nursing Assistant 2 [CNA 2]) removed their used gloves prior to exiting a resident room and failing to ensure CNA 2 performed hand hygiene (washing of hands) after removing a set of gloves. 3. Failing to ensure the facility's Infection Preventionist (IP) was able to articulate the facility's water management process to reduce the risk of Legionnaire's disease (a severe form of pneumonia [lung inflammation usually caused by infection]). 4. Facility failed to ensure the water management program was reviewed by the Infection Control Committee on an annual basis. These deficient practices had the potential to spread infection and cross contamination (the physical movement or transfer of harmful bacteria [germs] from one person, object, or place to another) among staff and other residents. Findings: 1. During an observation on 11/18/2023, at 9:33 a.m., observed MA walking through the facility's hallway wearing a pair of gloves. During a concurrent observation and concurrent interview with MA on 11/18/2023, at 9:34 a.m., MA stated that he was presently wearing gloves while in the hallway, and that MA's gloves are clean because he has not been inside a resident's room. When asked if MA is supposed to wear gloves in the facility's hallway, MA stated that he is not supposed to wear gloves in the hallway because of infection control concerns. During an interview with the Infection Preventionist (IP), on 11/19/2023 at 4:28 p.m., the IP stated that staff should not be wearing gloves in the hallway even if staff have not entered a room for infection control. 2. During an observation on 11/18/2023, at 9:46 a.m., observed CNA 2 exit a resident's room wearing gloves. Observed CNA 2 then removed the pair of gloves and disposed the gloves at a trash receptacle attached to a medication cart. CNA 2 was observed not performing hand hygiene. During an interview with CNA 2 on 11/18/2023 at 9:55 a.m., CNA 2 stated that she did not remove her used gloves prior to exiting a resident's room. CNA 2 stated that she should have removed her gloves prior to exiting the resident's room and disposed the used gloves inside the resident's room. CNA 2 continued to state that after removing her gloves and disposing them she should have performed hand hygiene because it is important for infection control purposes. During an interview with the Infection Preventionist (IP), on 11/19/2023 at 4:28 p.m., the IP 555519 Page 17 of 21 555519 11/19/2023 The Care Center on Hazeltine, LLC 6835 Hazeltine Ave. Van Nuys, CA 91405

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated that the proper procedure of removing used gloves is to remove used gloves prior to exiting a resident's room, dispose the used gloves in the trash bin that's located inside the resident's room, and then perform hand hygiene by washing hands with soap and water or using hand sanitizer to prevent the spread of germs and for infection control. A review of the facility's policy and procedure titled Infection Prevention and Control Program, review date 9/25/2023, indicated the facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infection. The facility's infection control policies and procedures apply to all facility staff, consultants, contractors, residents, visitors, volunteer workers, and the general public. A review of the facility's policy and procedure titled Hand Hygiene, review date 9/25/2023, indicated all facility staff are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare associated infections. Facility staff must perform hand hygiene procedures in the following circumstances: A. Wash hands with soap and water: viii. In between glove changes. B. Alcohol-based hand hygiene products can and should be used to decontaminate hands: ii. Immediately upon exiting a resident occupied area (e.g., before exiting into a common area such as a corridor) regardless of glove use; V. After removing personal protective equipment (PPE) and before moving to another resident in the same room or exiting the room. Hand hygiene is always the final step after removing and disposing of personal protective equipment. 3. During an interview with the IP on 11/19/2023 at 4:39 p.m., the IP was asked to describe the facility's water management program. The IP was unable to articulate the facility's water management program and stated she does not know anything about the facility's water management program. The IP stated that the water management program was the responsibility of the maintenance department. During an interview with the Director of Nursing (DON) on 11/19/2023 at 7:08 p.m., the DON stated that it is the responsibility of the IP to have knowledge of the facility's water management because Legionnaire's disease is a reportable disease and is part of the infection prevention and control program. A review of the facility's policy and procedure titled Infection Prevention and Control Program, review date 9/25/2023, indicated the facility establishes and maintains an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with Federal and State regulations. 4. During an interview and concurrent record review with the IP on 11/19/2023 at 6:56 p.m., the IP stated that the Infection Control Committee meets annually (once a year). The IP reviewed the facility's document titled Infection Control Committee, Minutes of Meeting, dated 5/15/2023. When asked if the water management program was reviewed and discussed during the Infection Control Committee 555519 Page 18 of 21 555519 11/19/2023 The Care Center on Hazeltine, LLC 6835 Hazeltine Ave. Van Nuys, CA 91405

F 0880 Level of Harm - Minimal harm or potential for actual harm meeting on 5/15/2023, the IP stated that the water management program was not reviewed or discussed because she was not aware that the water management program had to be reviewed or discussed during the annual Infection Control Committee meetings. When asked what the importance of reviewing and discussing the water management program with the Infection Control Committee, the IP was unable to answer. Residents Affected - Some The facility's policy and procedure titled Legionella, review dated 9/25/2023, indicated the water management program will be reviewed by the Infection Control Committee no less than annually. 555519 Page 19 of 21 555519 11/19/2023 The Care Center on Hazeltine, LLC 6835 Hazeltine Ave. Van Nuys, CA 91405

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to implement the facility's antibiotic stewardship program (a coordinated program that promotes the appropriate use of drugs used to treat infections, including antibiotics [a medicine that inhibits the growth of or destroys bacteria or germs]) by failing to ensure the facility's monthly surveillance monitoring report was completed for 9/2023 and 10/2023. Residents Affected - Some This deficient practice had the potential for residents to develop antibiotic resistance from unnecessary or inappropriate antibiotic use for future infections. Findings: During a concurrent interview and record review on 11/17/2023 at 7:29 p.m., with the Infection Preventionist (IP), the IP stated that the antibiotic stewardship program is a program that monitors the antibiotics used in the facility to ensure residents are appropriately prescribed antibiotics. The IP stated when the facility receives a physician's order for antibiotics for a resident, the licensed nurse will then fill out a surveillance date collection form (a systematic collection of data to track infection which is collected when a resident has certain signs and symptoms that could be a bacterial infection). The IP continued to state that at the end of each month, the IP will collect and review all the surveillance date collection forms to monitor and track residents who were prescribed antibiotics. The IP stated this information collected is used to create a monthly surveillance report. When asked to see the monthly surveillance reports for 2023, the IP was unable to provide documented evidence that the monthly surveillance reports were completed for 9/2023 and 10/2023. When asked why 9/2023 and 10/2023 have not been completed, the IP stated that she has been so behind and has not found the time to complete the surveillance monitoring reports. A review of the facility's policy and procedure titled, Antibiotic Stewardship Program, review date 9/25/2023, indicated the Antibiotic Stewardship Program (ASP) is designed to promote appropriate use of the antibiotics while optimizing the treatment of infections, and simultaneously reducing the possible adverse events associated with antibiotic use. The IP will analyze infection surveillance data and monitor the adherence to the ASP and create a report to the Consultant Pharmacist identifying the number of residents on antibiotics that did not meet the criteria for active infection and suggest appropriate overall changes to make a successful, well-rounded program. Under Tracking: The IP will be responsible for review of infection surveillance and multidrug-resistant organism (MDRO- organism at are resistant to three or more classes of antimicrobial drugs) tracking. The IP will measure and report outcomes and success rate at monthly/quarterly Infection Control Committee (ICC) meetings. 555519 Page 20 of 21 555519 11/19/2023 The Care Center on Hazeltine, LLC 6835 Hazeltine Ave. Van Nuys, CA 91405

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to implement the facility's pneumococcal vaccine (prevents infection from pneumonia [infection that infects one of both lungs]) policy by failing to ensure one of five sampled residents (Resident 36) was provided education regarding the pneumococcal vaccine. Residents Affected - Few This deficient practice had the potential for Resident 36 to not be aware of the risks and benefits of the pneumococcal vaccine. Findings: A review of Resident 36's admission Record indicated the facility readmitted the resident on 4/15/2021 with diagnoses that included encounter for attention to gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), type two diabetes mellitus (a condition that affects the way the body processes blood sugar) with hyperglycemia (high blood sugar), and dysphagia (difficulty swallowing). A review of Resident 36's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 9/19/2023, indicated Resident 36 had intact cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making. The MDS indicated Resident 36 was totally dependent with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. During a concurrent interview and record review on 11/19/2023 at 5:00 p.m., with the Infection Preventionist (IP), reviewed Resident 36's immunization record. The IP stated that Resident 36 refused the pneumococcal vaccine. The IP stated that prior to the administration of any vaccine, education will be provided to the resident and/or responsible party. The IP stated education will be provided verbally and a vaccine information sheet will also be provided to the resident and/or responsible party. The IP continued to state that documentation is completed in the resident's medical record indicating education was provided. The IP stated that there was no documented evidence that education was provided to Resident 36 or to Resident 36's responsible party regarding the pneumococcal vaccine. The IP further stated that if there is no documentation of the education provided, then the education was not done because there is no proof. A review the facility's policy and procedure titled Pneumococcal Disease Prevention, reviewed date 9/25/2023, indicated before offering a pneumococcal vaccine, each resident or the resident's legal representative receives education regarding the benefits and potential side affects of the immunization. The policy continues to indicate that the resident's medical record includes documentation that indicates, at a minimum, the following: That the resident or resident's legal representative was provided education regarding the benefits and potential side effects of the pneumococcal vaccine. That that resident was given a copy of IC-20-Form C-PPSV/PCV-Informed Consent/Refusal (consent used to provide residents and resident representatives with information regarding the risk and benefits of a vaccine) which is to be placed in the resident's medical record. 555519 Page 21 of 21