Health inspection·December 19, 2023

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the basis for the discharge and/or the discharge summary was documented by the attending physician for one (1) of three (3) sampled residents (Resident 34). This deficient practice resulted in incomplete records for Resident 34. Findings: A review of Resident 34's Face Sheet (admission record) indicated the facility admitted Resident 34 on 9/24/2014, with diagnoses that included hemiplegia (paralysis/loss of the ability to move of one side of the body) and hemiparesis (one-sided muscle weakness) following a cerebral infarction (stroke, when something blocked blood supply to part of the brain or when a blood vessel in the brain busted) affected the left non-dominant side. The admission record indicated Resident 34 was admitted to the facility on [DATE] and discharged on 10/29/2023. A review of a document titled, Family Medicine Office/Clinic Note, dated 8/10/2023, indicated Resident 34 was alert and oriented to self, time, place, and situation. The note indicated Resident 34 was able to make daily decisions. The Note indicated Resident 34 was doing well. A review of Resident 34's physician notes did not indicate that the physician completed a discharge summary. During an interview with the Medical Records Staff (MRS) 1 on 12/18/2023 at 6:23 PM, the MRS 1 stated the discharge summary for Resident 34 was not completed. The MRS 1 stated the discharge summary should be initiated by the discharging nurse and printed out for the physician to sign. The MRS 1 stated upon Resident 34's discharge, the MRS 1 is supposed to make sure the discharge summary was signed. During an interview with the Director of Nursing (DON) on 12/18/2023 at 7:01 PM, the DON stated it is the responsibility of the licensed nurse doing the resident's discharge to provide the discharge summary paper, all medications, and education to whoever is responsible for the resident. The DON stated, for death, there is no discharge summary. When asked if death was considered a discharge from facility, the DON stated No. A review of the facility's policy and procedure titled Transfer and Discharge Planning, dated 6/1/2021 indicated a copy of the Discharge Summary and Discharge Care Plan will be maintained in the Page 1 of 22 555616 555616 12/19/2023 Ararat Post Acute 1230 E. Windsor Rd. Glendale, CA 91205

F 0622 Level of Harm - Minimal harm or potential for actual harm resident's medical record. The policy indicated the discharge summary will include recapitulation of the resident's stay including, but not limited to, diagnoses, course of illness, treatment, and pertinent lab, radiology, and other consultation results. Residents Affected - Few 555616 Page 2 of 22 555616 12/19/2023 Ararat Post Acute 1230 E. Windsor Rd. Glendale, CA 91205

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 develop and implement an individualized person-centered plan of care with measurable objectives, timeframe, and interventions to meet the residents' needs for seven (7) of 13 sampled residents (Resident 6, 13, 87, 4, 19, 14, and 4) by failing to: 1. Develop an individualized/person- centered care plan for Resident 6 while receiving Eliquis (blood thinner - a medication that thins the blood and could cause bruising or bleeding) 2. Develop an individualized/person-centered care plan with goals and interventions for Resident 13 who has a diagnosis of type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar) while receiving insulin. 3. Develop an individualized/person- centered care plan for Resident 87 who has a diagnosis of type 2 diabetes mellitus while receiving insulin and Aspirin (a medication that prevents blood clot to form). 4. Developed a plan of care for Resident 4 for management of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and a care plan to monitor the resident for side effects and specific behaviors to monitor for the use of Paxil (a medication used to treat depressive disorder and anxiety [having the fear of the unknown]) as ordered by the physician. 5. Developed a plan of care to monitor Resident 19, for the side effects of Aspirin (a medication that prevent the blood clots to form which could lead to serious bleeding and bruising) used for prophylaxis (action taken to prevent disease) and Depakote (also known as Divalproex Sodium- an anticonvulsant [prevent epilepsy or abnormal brain activity], medication to used treat seizure disorders and manage bipolar disorder (mental illness causes extreme mood swings that include emotional highs [mania] or emotional lows [hypomania or depression]) as ordered by the physician. 6. Developed a plan of care to monitor Resident 14 for side effects of Aspirin as ordered by the physician. 7. Developed a plan of care for Resident 7 to manage Diabetes Mellitus (a group of diseases that affect how the body uses blood sugar [glucose]), and the use of Insulin (an essential hormone that helps the body turn food into energy and controls by lowering glucose levels in the body). These deficient practices had the potential for the residents to not receive appropriate care treatment and/or services to achieve their highest potential. Findings: 1. During a review of Resident 6's admission Record, indicated the facility admitted Resident 6 on 4/30/2023 with diagnoses that included paroxysmal atrial fibrillation (irregular and often faster heartbeat) and type 2 diabetes mellitus (DM - a chronic condition that affects the way the body processes blood sugar). 555616 Page 3 of 22 555616 12/19/2023 Ararat Post Acute 1230 E. Windsor Rd. Glendale, CA 91205

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 6's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/18/2023, the MDS indicated, Resident 6's cognition for daily decision making was intact. The MDS indicated, Resident 6 required moderated assistance with oral hygiene, toileting hygiene, upper and lower body dressing, and personal hygiene. During a review of Resident 6's Physician Order, dated 4/30/2023, indicated to administer Eliquis oral tablet 5 milligrams (mg-unit of measurement) one tablet by mouth, twice daily for paroxysmal atrial fibrillation. During a concurrent interview and record review on 12/16/2023 at 12:10 pm with the facility's Director of Nursing (DON), Resident 6's medical record was reviewed. The DON stated there was no other clinical documentations that a CP was developed for Resident 6 who was on Eliquis therapy. The DON stated care plan should have been developed and implemented for the management of Eliquis to ensure Resident 6 receive the proper care and effective interventions from the nursing staff as needed. 2. During a review of Resident 13's admission record indicated, the facility admitted Resident 13 on 4/14/2023 with diagnoses that included type 2 DM and dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). During a review of Resident 13's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/10/2023, the MDS indicated, Resident 13's cognition for daily decision making was intact. Resident 13 required moderated assistance with toileting, shower, and lower body dressing. During a review of Resident 13's Physician order, dated 10/19/2023, indicated to inject Basaglar Kwik Pen insulin (Insulin Glargine - long-acting insulin [a hormone that works by lowering levels of sugar in the blood]) 28 units subcutaneously (administering medication where a short needle is used to inject a medication into the tissue layer between the skin and the muscle) one time a day for type 2 DM. During a concurrent interview and record review on 12/16/2023 at 12:15 pm with the facility's DON, Resident 13's medical record was reviewed. The DON stated there was no clinical documentations that CP was developed and implemented for Resident 13 who has a type 2 DM and receiving insulin therapy. The DON stated a care plan should have been developed and implemented for the management of diabetes for Resident 13 to ensure the resident receive the proper care and effective interventions from the nursing staff as needed. 3. During a review of Resident 87's admission record indicated, the facility admitted Resident 13 on 12/8/2023 with diagnoses that included type 2 DM and long term use of insulin (a hormone that helps control your body's blood sugar level) use. During a review of Resident 87's History and Physical (H&P), dated 12/11/2023, indicated Resident 87 did not have the capacity to understand and make decisions. During a review of Resident 87's Physician Order, dated 11/10/2022, indicated to administer Humulin R (type of insulin) subcutaneously per sliding scale coverage (progressive increase in the insulin dose, based on pre-defined blood glucose ranges) before meals and at bedtime for diabetes. 555616 Page 4 of 22 555616 12/19/2023 Ararat Post Acute 1230 E. Windsor Rd. Glendale, CA 91205

F 0656 During a review of Resident 87's Physician Order, dated 12/08/2022, indicated to Level of Harm - Minimal harm or potential for actual harm Administer Aspirin tablet 81 milligrams (mg) one tablet by mouth, in the evening for Cerebrovascular Accident (CVA, death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired) prophylaxis (prevention) with dinner. Residents Affected - Some During a concurrent interview and record review on 12/16/2023 at 12:28 pm with the facility's DON, Resident 87's medical record was reviewed. The DON stated there was no other clinical documentations that CP was developed and implemented for Resident 87 with a diagnosis of type 2 diabetes mellitus and receiving insulin therapy. The DON stated a care plan should have been developed and implemented for Resident 87 for the management of diabetes to ensure the resident receive the proper care and effective interventions from the nursing staff as needed. During a review of the facility's Policy and Procedure (P&P) titled, Care Planning, revised 10/24/2022, indicated the facility's Interdisciplinary Team (IDT) will develop a Baseline and/or Comprehensive Care Plan for each resident. 4. A review of Resident 4's Facesheet (a document that gives a patient's information at a quick glance) indicated an admission to the facility on 9/8/2022 with diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction (stroke) affection left non-dominant side, dysphagia (difficulty swallowing), and major depressive disorder. A review of Resident 4's History and Physical assessment dated [DATE], indicated Resident 4 had previous medical history of age-related cognitive decline (natural process in which older adults typically experience decline in many functions, such as memory, thinking, concentration). A review of Resident 4's Order Summary Report dated 9/8/2022, indicated a physician order was made for Paxil Oral Tablet 10 milligrams (mg-a unit of measure) give 1 tablet by mouth at bedtime related to major depressive disorder, single episode, severe without psychotic (psychosis, refers to a collection of symptoms that affect the mind, where there has been some loss of contact with reality) features, manifested by verbalization of sadness. Resident 4's Order Summary indicated to monitor behavior for verbalization of sadness every shift for Paxil use. During a concurrent interview and record review of Resident 4's care plans on 12/17/2023 at 10:42 AM, the Director of Nursing (DON) stated there was no documented evidence that indicated how Resident 4 was monitored for the use of Depakote and management of major depressive disorder. The DON stated it was important to have a care plan to know how to take care of the resident. The DON stated it was her fault the care plans were not transferred from the old documentation software (computerized charting) to the new documentation software they are currently using. 5. A review of Resident 19's Facesheet indicated an admission to the facility on 4/15/2022 with diagnoses that included transient cerebral ischemic attack (stroke, occurs when the blood supply to part of the brain is briefly interrupted), hypertensive heart disease (problems with heart that can develop because of high blood pressure that is present over a long time) with heart failure (also known as congestive heart failure, a condition that develops when the heart doesn't pump enough blood for your body's needs) and bipolar disorder. A review of Resident 19's History and Physical assessment dated [DATE] indicated Resident 19 had 555616 Page 5 of 22 555616 12/19/2023 Ararat Post Acute 1230 E. Windsor Rd. Glendale, CA 91205

F 0656 age-related cognitive decline. Level of Harm - Minimal harm or potential for actual harm A review of Resident 19's Order Summary Report: Residents Affected - Some a. Dated 11/01/2023, indicated the physician ordered Resident 19 to receive chewable Aspirin 81 mg, one oral (given by mouth) tablet time a day for cerebrovascular accident (CVA, stroke) prophylaxis (prevention). b. Dated 7/27/2023, indicated the physician ordered Resident 19 to receive an anticoagulant (blood thinner)/Aspirin medication and to monitor the resident for discolored urine, black tarry stools, sudden severe headache, nausea & vomiting, diarrhea, muscle joint pain, lethargy (lack of energy and enthusiasm), bruising, sudden changes in mental status, shortness of breath and nosebleed, every shift. c. Dated 7/27/2023, indicated the physician ordered Resident 19 to receive Depakote Delayed Release 125 mg, one oral tablet, three times a day related to bipolar disorder, manifested by irritable mood with hallucinations (a false perception of objects or events involving your senses: sight, sound, smell, touch, and taste) seeing people from past. d. Dated 7/27/2023, indicated the physician ordered to monitor Resident 19 for behavior related to Depakote use that included: irritable mood with hallucinations seeing people from past, every shift, related to bipolar disorder. During a concurrent interview and record review of Resident 19's care plans on 12/17/2023 at 10:45 AM, the DON stated there was no documented evidence of a care plan that indicated how Resident 19 was monitored for the use of Aspirin and the use of Depakote. 6. A review of Resident 14's Facesheet indicated an admission to the facility on [DATE] with diagnoses that included aftercare following joint replacement surgery, aftercare following explanation of shoulder joint prosthesis (a device designed to replace a missing part of the body or to make a part of the body work better), and unspecified atrial fibrillation (an abnormal heartbeat). A review of Resident 14's History and Physical assessment dated [DATE] indicated Resident 14 had the capacity to understand and make decisions. A review of Resident 14's Order Summary Report: a. Dated 12/02/2023, indicated the physician ordered Resident 14 to receive chewable Aspirin 81 mg one tablet by oral, two times a day for CVA prophylaxis. b. Dated 11/30/2023, indicated the physician ordered to monitor Resident 14 for signs and symptoms of bruising/bleeding and to monitor for signs and symptoms of thromboembolism (occurs when a blood clot breaks off and blocks another blood vessel) every shift for Aspirin use. During a concurrent interview and record review of Resident 14's care plans on 12/17/2023 at 10:47 AM, the DON stated there was no documented evidence of a care plan that indicated how Resident 14 was monitored for the use of Aspirin. 7. A review of Resident 7's Facesheet indicated an admission to the facility on 6/29/2023 with 555616 Page 6 of 22 555616 12/19/2023 Ararat Post Acute 1230 E. Windsor Rd. Glendale, CA 91205

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some diagnoses that included cerebral infarction (stroke), surgical aftercare following surgery on the digestive system and type 2 diabetes mellitus (chronic condition that happens when one has persistently high blood sugar levels) without complications. A review of Resident 7's History and Physical assessment dated [DATE] indicated Resident 7 did not have the capacity to make her own decisions. A review of Resident 7's Order Summary Report, dated 10/12/2023, indicated the physician ordered Resident 7 to receive NovoLOG (rapid-acting insulin that lowers the blood sugar level) FlexPen Subcutaneous (injection with a syringe and needle under the skin) Solution Pen-Injector 110 UNIT/ML, inject as per sliding scale: if 150-200 = 1 unit; 201-250= 2 units; 251-300=3 units; 301-350= 4 units; 351-400= 5 units; >400= 6 units, call physician if blood sugar (BS) > 400 or <60, given subcutaneously before meals and at bedtime. During a concurrent interview and record review of Resident 7's care plans on 12/17/2023 at 10:50 AM, the DON stated there was no documented evidence of a care plan that indicated how Resident 7 was monitored for the use of insulin and how Resident 7's diabetes was being managed. 555616 Page 7 of 22 555616 12/19/2023 Ararat Post Acute 1230 E. Windsor Rd. Glendale, CA 91205

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide immediate cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure, consisting of a combination of chest compressions, mouth-to-mouth, or mechanical breathing [a device used to help someone breathe], performed when the heart stops beating or beats ineffectively and/or to restore breathing), and call 911 (emergency services and/or emergency transfer to the general acute care hospital) for one (1) of three (3) sampled residents (Resident 34), who had a full code status (when resident's heart stopped beating and/or the resident stopped breathing, the resident or his/her representative wished for all lifesaving procedures to be provided to keep the resident alive) by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 1 started CPR on [DATE] at around 11 AM when LVN 1 found Resident 34 unresponsive, in accordance with the facility's policies titled, Physician Orders For Life Sustaining Treatment (POLST, a written medical order that indicated a patient/resident lifesaving treatment wishes), Medical Emergencies- Code Blue (an announcement used to indicate a patient/resident requiring resuscitation or otherwise in need of immediate medical attention, most often as the result of a cardiac arrest [the heart stopped beathing/pumping blood) or respiratory arrest [the lungs stopped working/breathing]), and Emergency Care - General. 2. Ensure Registered Nurse (RN) 1 started CPR immediately, provided full CPR with rescue breathing (inhaling into the patient's/resident's airway and lungs using mouth-to-mouth breathing or mechanical breathing), and sent LVN 1 to call 911 after RN 1 entered Resident 34's room on [DATE] at 11:02 AM, and found Resident 34 unresponsive, in accordance with the facility's policies titled, Physician Orders For Life Sustaining Treatment, Medical Emergencies- Code Blue, and Emergency Care - General. As a result, on [DATE], Resident 1 did not receive immediate and full CPR with rescue breathing as indicated in Resident 34's POLST that Resident 34 wished to be resuscitated (to revive [restore to life] from apparent death or from unconsciousness or provided with CPR, to prolong life by all medically effective means). RN 1 pronounced Resident 34 expired on [DATE] at 11:02 AM and informed Resident 34's Attending Physician (Physician 1) on [DATE] at 11:06 AM that Resident 34 had expired. On [DATE] at 8:47 PM, while onsite at the facility, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation have caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified. The surveyor notified the Administrator (ADM) and the Director of Nursing (DON), regarding the facility's failure to provide basic life support (BLS, the type of care that first-responders, healthcare providers and public safety professionals provide to anyone who is experiencing cardiac arrest, respiratory distress or an obstructed airway), including immediate, full CPR with rescue breathing, and call 911 for Resident 34, who had a full code status on [DATE] at 11:02 AM, and the risk for 20 other residents who were residing in the facility with full code status not receiving immediate and full CPR when those residents' hearts stopped beating and or when they stopped breathing. The IJ was called in the presence of the facility's ADM and DON. On [DATE], at 11:45 AM, the facility submitted an acceptable IJ Removal Plan ([Plan of Action] a list of steps taken to correct the deficient practices). The IJ was removed on [DATE] at 5:12 PM, in the presence of the facility's ADM and DON, while onsite at the facility, after the surveyor verified and confirmed the facility's approved IJ Removal Plan (a detailed plan to address the IJ findings) 555616 Page 8 of 22 555616 12/19/2023 Ararat Post Acute 1230 E. Windsor Rd. Glendale, CA 91205

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few was fully implemented through observations, interviews, and record reviews, in a manner that eliminated the likelihood of serious injury, serious harm, serious impairment, or death with 20 other residents residing in the facility with full code status. The acceptable IJ Removal Plan, dated [DATE] included the following: a. On [DATE], the Director of Staff Developer (DSD) created the BLS (Basic Life Support) Skills Competency Checklist about Code Blue situation. The DSD would provide the in-service about the BLS and Cod Blue situation to LVN 1 by [DATE] after LVN 1 returned from vacation. b. On [DATE], the DON initiated the in-service education for all Licensed Nurses (LVNs and RNs) from three shifts (morning [7 AM to 3 PM,] evening [3 PM to 11 PM,] and night shifts [11 PM to 7 AM,] on Emergency Care Policy, CPR and calling 911. c. On [DATE], the DSD and the DON initiated the BLS Skills Competency checklist for 15 Licensed Nurses Competency Checklist would be completed once a week for four (4) weeks, once a month for three (3) months, then quarterly for one year. d. On [DATE], the DON initiated in-service education for all licensed nurses (in general) who worked on [DATE] for the morning, evening, and night shifts on the facility's policy and procedure [NAME], Change of Condition Notification, for residents who have no pulse, unresponsive, and have undetected vital signs (clinical measurements, specifically pulse rate [number of heart beat per minute], temperature [a measurement of the body making and releasing heat], respiration rate [number of breaths per minute], and blood pressure [the force of the blood pushing against the walls of the arteries/blood vessels]). Any nursing staff (RNs, LVNs and CNAs in general) who did not complete the BLS Skills Competency checklist by [DATE] would not be scheduled to work until they completed the in-service education for the BLS Skills Competency Checklist. e. On [DATE], the DSD initiated weekly mock (simulation/pretend) code blue medical emergency drills for 4 weeks to monitor nursing staff's (in general) compliance with the facility's Emergency Care policy. f. On [DATE], the DON completed the BLS Skills Competency Checklist about Code Blue situation that was created by the DSD for RN 1. g. On [DATE], Medical Record Staff (MRS) 1 completed the audit of all Active Resident POLST forms and uploaded the forms into the online documentation software for electronic medical records for quick reference. h. On [DATE], outside BLS Trainer with BLS instructor credentials from the American Heart Association initiated First Aid CPR training for RNs, LVNs, and CNAs (in general). The BLS trainer would be completed the CPR training for all nursing staff from 3 shifts (morning, evening, and night shifts) by [DATE]. Findings: A review of Resident 34's Face Sheet (admission record) indicated the facility admitted Resident 34 on [DATE], with diagnoses that included hemiplegia (paralysis/loss of the ability to move of one 555616 Page 9 of 22 555616 12/19/2023 Ararat Post Acute 1230 E. Windsor Rd. Glendale, CA 91205

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few side of the body) and hemiparesis (one-sided muscle weakness) following a cerebral infarction (stroke, when something blocked blood supply to part of the brain or when a blood vessel in the brain busted) affected the left non-dominant side. A review of a document titled, Family Medicine Office/Clinic Note, dated [DATE], indicated Resident 34 was alert and oriented to self, time, place, and situation. The note indicated Resident 34 was able to make daily decisions. The Note indicated Resident 34 was doing well. A review of Resident 34's Physician Orders for Life Sustaining Treatment (POLST) dated [DATE], and signed by Resident 34, indicated under Cardiopulmonary Resuscitation (If patient has no pulse and not breathing, showed a handwritten check mark on Attempt/Resuscitation/CPR. The POLST indicated under Medical Interventions showed a check mark on Full Treatment (primary goal of prolonging life by all medically effective means. A review of Resident 34's Progress Notes dated [DATE] timed at 12:53 PM, authored by RN 1 indicated the following events: - At 7 AM, Resident 34 was alert and able to make needs known. The progress note indicated The resident's RR (respiratory rate) was even and unlabored (produced without difficulty or exertion). No SOB (shortness of breath) noted at this time. The resident denied pain. There is no distress noted at this time. The resident is resting comfortably in bed. The resident's VS (vital signs): 98/60 (blood pressure), 61 (pulse rate), 97.8 (temperature), 19 (respiratory rate), PS (pain status): 0/10 (0 equal no pain, 10 equal the worst pain). The resident's oxygen saturation (oxygen level in the blood; 95% to 100% are generally considered normal) was 96%. - At 9 AM, Resident 34 was alert and able to make needs known. The note indicated There is no distress noted at this time. - At 10 AM, Resident (34) was alert and able to make needs known. The resident's RR was even and unlabored. No SOB noted at this time. The note indicated the resident is resting comfortably on the bed at this time. - At 11:02 AM, Resident 34 was noted to look pale. The RN could not detect the resident's pulse and blood pressure. The RN pronounced the resident expired at 11:02 AM. - At 11:06 AM, RN 1 notified the resident's primary doctor. The note indicated RN 1 received new order to endorse the resident's body to the mortuary service (as) requested by the family. During an interview with RN 1 and a concurrent review of Resident 34's Progress Notes dated [DATE] timed at 11:02 AM, on [DATE], at 2:49 PM, RN 1 stated on [DATE], when RN 1 entered Resident 34's room, RN 1 checked Resident 34's pulse and blood pressure. RN 1 stated Resident 34 had no vital signs on [DATE]. RN 1 stated Resident 34 looked pale, not responsive, but Resident 34's body was warm to touch. RN 1 stated RN 1 attempted CPR but RN 1 did not call 911 because Resident 34 had expired. RN 1 stated when the vital signs were not detected in a resident (in general), RN 1 would not call 911. RN 1 stated RN 1 attempted to perform CPR on Resident 34, but he did not document that he attempted the CPR on Resident 34 in Resident 34's Nurses Notes. During a continued interview with RN 1 on [DATE] at 3:03 PM, RN 1 stated that on [DATE], RN 1 was alone when RN 1 went into Resident 34's room. RN 1 stated RN 1 did not see Resident 34's chest rose, 555616 Page 10 of 22 555616 12/19/2023 Ararat Post Acute 1230 E. Windsor Rd. Glendale, CA 91205

F 0678 Level of Harm - Immediate jeopardy to resident health or safety and Resident 34 looked pale, on [DATE]. RN 1 stated RN 1 tried to get Resident 34's vital signs, on [DATE] but RN 1 could not get any vital signs. RN 1 stated RN 1 left Resident 34's room to check on Resident 34's POLST and immediately went back to Resident 34's room and started to perform CPR by himself. RN 1 stated at the time, Resident 34's skin color looked gray. RN 1 stated, RN 1 performed chest compressions for five minutes. RN 1 stated There was no pulse or vitals, the patient's (Resident 34's) vital signs were gone. Residents Affected - Few During a telephone interview with LVN 1 on [DATE] at 3:05 PM, LVN 1 stated on [DATE] (did not remember exact time) about 30 minutes prior to finding Resident 34 unresponsive, Resident 34 was alert and awake. LVN 1 stated LVN 1 found Resident 34 unresponsive and LVN 1 notified RN 1. LVN 1 stated they (RN 1 and LVN 1) assessed Resident 34 and the resident had no pulse, no blood pressure, nothing. LVN 1 stated Resident 34 was a full code, and they (RN 1 and LVN 1) did not perform CPR on Resident 34. LVN 1 stated LVN 1 did not see RN 1 performed CPR on Resident 34 and they (LVN 1 and RN 1) did not call 911. LVN 1 did not respond when asked why LVN 1 did not perform CPR for Resident 34 knowing Resident 34 was a full code. During an interview with the DON on [DATE], at 3:07 PM, the DON stated when a resident had a full code status, facility staff (in general) needed to attempt CPR, and call 911. The DON stated it was important to call 911 due to the paramedics (medical professionals who specializes in emergency treatment) might be able to revive Resident 34. The DON stated, Full code means you call 911 and at least you try to save the patient (resident). During another interview with RN 1 on [DATE] at 3:28 PM, RN 1 stated on [DATE] (did not state the time) before RN 1 attempted CPR on Resident 34, RN 1 called a code blue but there was nobody (no staff available). RN 1 stated LVN 1 was in Resident 34's room helped RN 1 with putting the papers. RN 1 stated LVN 1 helped immediately, but RN 1 could not recall exactly what LVN 1 did during that time. RN 1 stated after 5 minutes of performing CPR on Resident 34, RN 1 notified Physician 1 that Resident 34 had expired. During an interview with Certified Nursing Assistant (CNA) 1 on [DATE] at 3:28 PM, CNA 1 stated she was assigned to Resident 34 and was on lunch break on [DATE] (did not remember the time), when RN 1 found Resident 34 unresponsive. CNA 1 stated when she returned from lunch break, Resident 34 had already expired. CNA 1 stated she did not recall any code blue being called on [DATE]. During a telephone interview with CNA 2 on [DATE] at 4:22 PM, CNA 2 stated she worked on [DATE] (with CNA 1) during the 7 AM to 3 PM shift. CNA 2 recalled that on [DATE] (did not remember exact time), during the morning shift, Resident 34 was alert and awake. CNA 2 stated on [DATE], none of the facility's staff called a Code Blue. During a telephone interview with Resident 34's family member (Family) 1 on [DATE] at 4:25 PM, Family 1 stated Resident 34 changed Resident 34's POLST around a month before Resident 34 passed away to full code status. Family 1 stated Resident 34 wished to receive full medical treatment including CPR. During a concurrent review of Resident 34's Progress Notes, dated [DATE], timed 11:02 AM, and interview with the DON on [DATE] at 5:03 PM, the DON stated a physician (in general) needed to pronounce Resident 34 expired and not RN 1. The DON stated RN 1 should have called 911 and 911's staff (paramedics) would pronounce when Resident 34 expired. The DON stated the paramedics needed to check if there was no more life or if they (the paramedics) can provide Advance Life Support (ALS, referred to 555616 Page 11 of 22 555616 12/19/2023 Ararat Post Acute 1230 E. Windsor Rd. Glendale, CA 91205

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few as Advanced Cardiac Life Support [ACLS], was a set of life-saving protocols and skills that extend beyond BLS) to revive Resident 34, especially Resident 34 had a full code status. During another interview with RN 1 on [DATE] at 5:12 PM, RN 1 stated he needed to call 911 and performed CPR until the physician (in general) pronounced the resident's death. RN 1 stated he could not recall how many chest compressions he performed and RN 1 stated he did not use a bag valve mask (BVM, a type of device known as a bag valve mask, used to provide respiratory support to patients/residents) to provide rescue breathing, RN 1 stated I just try to pump her heart. During a telephone interview on [DATE] at 5:24 PM with Physician 1, who was also the facility's Medical Director, stated that the expectation for the licensed nurses during emergency situations was to perform CPR for full code residents and someone is delegated to call the attending physician or 911. Physician 1 stated it was acceptable for licensed nurses to call 911 first before calling the physician if the resident was not breathing. Physician 1 stated they (licensed nurses) do have the ability to call 911 . for a full code resident. During a concurrent interview and record review on [DATE] at 6:01 PM. The facility's policy and procedure titled, Emergency Care, dated [DATE] (the current policy and procedure provided by the facility), indicated for staff to immediately call 911 for medical emergency assistance during an emergency. The DON stated during emergency situations, facility's staff (in general) needed follow the facility's policy. The DON stated 911 emergency services needed to be called when Resident 34 was not breathing, pulseless, and/or unresponsive, to get help from the paramedics and preserve Resident 34's life. A review of the facility's policy and procedure titled, Emergency Care - General, revised on [DATE] (the current policy and procedure provided by the facility), indicated the purpose of the policy was to give emergency treatment to residents .to prevent further harm, and promote recovery. The policy indicated for facility's staff to determine the nature of the injury/illness .and to summon help and immediately call 911 for medical emergency assistance. The policy indicated these emergency situations would include but are not limited to Cessation of breathing (stop breathing), blockage of airway, pulseless victim .new onset of unconsciousness or unresponsiveness to verbal or physical stimuli. The policy indicated the licensed nurse's role during a code blue included to lead the code blue in the absence of a physician and coordinate the resuscitation efforts until paramedics arrive. The policy indicated that the licensed nurse would assure that . CPR has been initiated, 911 had been called, code blue had been paged overhead, and emergency cart was on the scene. A review of the facility's policy and procedures titled, Medical Emergencies- Code Blue, revised on [DATE] (the current policy and procedure provided by the facility), indicated the following information: 1. The first of facility personnel to arrive and find a resident with any of the above condition . that included Respiratory or Cardiac arrest, should call for help. 2. Send available staff to call a Code Blue and retrieve emergency medical equipment: 3. Assess the resident's level of consciousness, circulation, airway, and breathing; begin CPR according to current practice. A review of the facility's policy and procedure titled, Physician Orders for Life Sustaining 555616 Page 12 of 22 555616 12/19/2023 Ararat Post Acute 1230 E. Windsor Rd. Glendale, CA 91205

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Treatment (POLST), revised on [DATE] (the current policy and procedure provided by the facility), indicated the purpose of the policy was to help ensure that Facility honors residents' treatment wishes concerning resuscitation and life sustaining treatment. The policy indicated The POLST is a voluntary form used statewide as a physician order form that converts a resident's wishes regarding life-sustaining treatment and resuscitation into physician orders. The policy further indicated A valid POLST form is to be honored across treatment settings. Residents Affected - Few A review of the facility's policy and procedure titled Change of Condition Notification, revised on [DATE] (the current policy and procedure provided by the facility), indicated the definition of an acute change of condition (ACOC) is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. The policy indicated If the resident deteriorates, the symptoms are serious, and the most rapid intervention available by a physician would place the resident in great jeopardy, call 911 for transport to hospital. A review of the American Heart Association CRP & First Aid Emergency Cardiovascular Care website titled, Algorithms, for the year of 2023, the website indicated for adults, look for no breathing or only gasping and check pulse (simultaneously) and if pulse is felt within 10 seconds with no normal breathing, then to provide rescue breathing, one (1) breath every six (6) seconds or 10 breaths per minute, check pulse every two (2) minutes and if no pulse, start CPR. The website indicated, when CPR is started, perform cycles of 30 chest compressions and two (2) breaths and resume CPR cycles until an ALS provider arrived over or the victim started to move. [https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/algorithms#adult] 555616 Page 13 of 22 555616 12/19/2023 Ararat Post Acute 1230 E. Windsor Rd. Glendale, CA 91205

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 prevent unnecessary use of medication for three of five sampled residents (Resident 6, Resident 88, and Resident 7) who were not assessed and monitored for complications related to anticoagulant therapy (a medication prevent or delays blood clot to form, also known as blood thinner ) such as bleeding and bruising as indicated in the facility's policy and procedure titled, Anticoagulation Therapy Fact Sheet and the residents plan of care. Residents Affected - Some This deficient practice had the potential to result in Resident 6, Resident 88, and Resident 7's to have undetected bruising and bleeding which could result in blood loss and bleeding in the brain and other major organs to bleed without immediate interventions and lead to a decline in the resident's wellbeing. Findings: 1. During a review of Resident 6's admission Record, indicated the facility admitted Resident 6 on 4/30/2023 with diagnoses that included paroxysmal atrial fibrillation (irregular and often faster heartbeat) and type 2 diabetes mellitus (DM - a chronic condition that affects the way the body processes blood sugar). During a review of Resident 6's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/18/2023, the MDS indicated, Resident 6's cognition for daily decision making was intact. The MDS indicated, Resident 6 required moderated assistance (resident participate in the care) with oral hygiene, toileting hygiene, upper and lower body dressing, and personal hygiene. During a review of Resident 6's Physician Order, dated 4/30/2023, indicated to administer Eliquis (an anticoagulant) 5 milligrams (mg) one tablet by oral (by mouth), twice daily for paroxysmal atrial fibrillation (a rapid, erratic heart rate begins suddenly and then stops on its own within 7 days). During a concurrent interview and record review on 12/16/2023 at 12:19 pm, the facility's Director of Nursing (DON) Resident 6's medical record was reviewed. The DON stated there was no other clinical documentation that Resident 6 was assessed or monitored for side effects of anticoagulant use. The DON stated residents who were receiving anticoagulants should be assessed and monitored for signs and symptoms of bleeding because the residents could easily get skin discoloration or bleed easily. 2. During a review of Resident 88's admission Record, indicated the facility admitted Resident 88 on 12/13/2023 with diagnoses that included unspecified systolic heart failure (a condition that develops when heart doesn't pump enough blood for your body's needs) and hypertension (high blood pressure). During a review of Resident 88's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/17/2023, the MDS indicated, Resident 88's cognition for daily decision making was intact. Resident 88 required moderated assistance with oral hygiene, toileting hygiene, upper and lower body dressing, and personal hygiene. During a review of Resident 88's Physician Order, dated 12/13/2023, indicated to administer Eliquis oral tablet 5 mg one tablet by mouth, twice daily to the resident for unspecified systolic heart 555616 Page 14 of 22 555616 12/19/2023 Ararat Post Acute 1230 E. Windsor Rd. Glendale, CA 91205

F 0757 failure. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 88's Care Plan titled, Anticoagulant Therapy, initiated on 12/13/2023, indicated Resident 88 was receiving anticoagulant therapy. The interventions indicated the nursing staff will monitor/document/report as needed adverse reactions (undesired effect) of anticoagulant therapy: blood tinged or red blood urine, black tarry stools, dark or bright red stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy (sleepiness or deep unresponsiveness), bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs and daily skin inspection and report abnormalities. Residents Affected - Some During a concurrent interview and record review on 12/16/2023 at 12:28 pm, the facility's Director of Nursing (DON) Resident 88's medical record was reviewed. The DON stated there was no clinical documentations that indicated Resident 8 was assessed or monitored for side effects of anticoagulant use. The DON stated, Residents 88 was on anticoagulant and resident should be assessed and monitored for signs and symptoms of bleeding because the residents could easily get skin discoloration or bleed easily. A review of the facility's policy and procedure titled, Anticoagulant Therapy Fact Sheet, revised June 2018, the P&P indicated, the licensed nurse should regularly inspect the patient or resident receiving oral anticoagulants and regularly inspect the patient from bleeding gums, bruises, melena (presence of blood in the stool), tarry stools. hematuria (presence of blood in the urine), and hematemesis (presence of blood in the emesis or vomit). 3. A review of Resident 7's Face sheet indicated an admission to the facility on 6/29/2023 with diagnoses that included cerebral infarction (stroke or interruption of blood flow to the brain due to blood clot or bleeding), surgical aftercare following surgery on the digestive system and type 2 diabetes mellitus (chronic condition that happens when one has persistently high blood sugar levels) without complications. A review of Resident 7's History and Physical assessment dated [DATE] indicated Resident 7 did not have the capacity to make her own decisions. A review of Resident 7's Order Summary Report, dated 12/14/2023, indicated the physician ordered Resident 7 to receive Eliquis (also known as Apixaban- a medication that prevent or delays blood clot formation or blood thinner) one 5 milligrams (mg, unit of measure) tablet given by oral (by mouth) by mouth two times a day for bilateral (both sides) DVT and to monitor Resident 7 for signs and symptoms of bruising/bleeding, and thromboembolism (obstruction of a blood vessel by a blood clot that has become dislodged from another site in the circulation). During a concurrent interview and record review of Resident 7's Medication Administration Record (MAR) with the Director of Nursing (DON) on 12/17/2023 at 11:22 AM, the DON stated she could not find documented evidence in the MAR for 12/14/2023 and 12/15/2023, that licensed nurses monitored the resident for adverse reaction of Eliquis such as bleeding/bruising. The DON stated the use of Eliquis should be monitored for Resident 7 for any discoloration, bruising, and bleeding. 555616 Page 15 of 22 555616 12/19/2023 Ararat Post Acute 1230 E. Windsor Rd. Glendale, CA 91205

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. Based on observation, interview, and record review, during the medication administration, the facility staff failed to ensure the opened (in-use) Basaglar KwikPen insulin (Insulin Glargine - long-acting insulin- a hormone that works by lowering levels of sugar in the blood) was marked with the date opened for one of four resident (Resident 13) as indicated in the facility policy. This deficient practice had the potential for Resident 13 to receive Basaglar KwikPen insulin (insulin pen) with less efficacy or adverse reaction (not desired effect) of insulin. Findings: A review of Resident 13 ' s admission record, indicated the facility admitted Resident 13 on 4/14/2023, with diagnoses that included Type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar) and dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). During a review of Resident 13 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/10/2023, the MDS indicated, Resident 13 ' s cognition for daily decision making was intact. A review of Resident 13's Physician order, dated 10/19/2023, indicated to inject Basaglar KwikPen, 28 units subcutaneously (administering medication where a short needle is used to inject a medication into the tissue layer between the skin and the muscle) one time a day for Type 2 diabetes mellitus. During a concurrent medication pass observation and interview on 12/17/2023, at 9:50 am, together with License Vocational Nurse (LVN) 2, upon inspection one Basalgar KwikPen was opened but not dated as to when it was first opened and used. LVN 2 stated it was important to label the insulin pen with an open date to know the medication was still effective. LVN 2 stated that based on the facility ' s policy, every insulin should be labeled with an open date and should be discarded after 28 days. During an interview on 12/17/2023 at 10:07 am, the facility ' s Director of Nursing (DON), stated that medications should be labeled with the open date. The DON stated that the efficacy and potency of the medication will be affected because Insulin will expire in 28 to 30 days based on the insulin storage guide from the pharmacy. During a review of the facility's policy and procedure (P&P) titled, Specific Medication Administration Procedures, dated 8/2008, indicated to check expiration date on package/container. The P&P indicated when opening a multi-dose container, place the date on the container. During a review of the pharmacy guide for Insulin storage, dated 8/25/2023, indicated Insulin Glargine 100 units/ml Pen, once in use discard unused portion after 28 days. During a review of the Humalog KwikPen's manufacturer's literature revised in 11/2023, indicated Do 555616 Page 16 of 22 555616 12/19/2023 Ararat Post Acute 1230 E. Windsor Rd. Glendale, CA 91205

F 0761 not use your Pen past the expiration date printed on the Label or for more than 28 days after you first start using the Pen. https://uspl.lilly.com/basaglar/basaglar.html#ug0 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555616 Page 17 of 22 555616 12/19/2023 Ararat Post Acute 1230 E. Windsor Rd. Glendale, CA 91205

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to follow it's policy and procedure on storing, preparing, distributing and serving food in accordance with professional standards for food service safety, proper sanitation and food handling practices by failing to ensure the Kitchen Aide (KA 1) 1 was wearing a hair net while cleaning the food preparation area. These deficient practices had the potential for residents to be at risk for contracting food borne illnesses (infections or irritations of the gastrointestinal tract caused by food or beverages that contain harmful bacteria, parasites, viruses, or chemicals). Findings: During an initial tour of the kitchen on 12/15/2023 at 7:19 pm, KA 1 was observed not wearing a hairnet or hair cover while cleaning the food preparation area. KA 1 stated, he forgot to wear the hairnet while in the kitchen. KA 1 stated it was important to wear a hairnet to prevent hair from falling into the kitchen utensils in the food preparation area. During an interview on 12/16/2023 at 11:49 am, the Head [NAME] (HC) stated, before entering the kitchen the staff should wear a hair net or cap because hair might fall in the food or kitchen utensils. During an interview on 12/16/2023 at 11:50 am, the Dietary Supervisor (DS) stated hairnet should be always worn by staff while inside the kitchen. The DS stated, the staff's hair could fall or drop in the food, or kitchen utensils if staff were not wearing hairnet or hair covered when preparing food and contaminate the food and cause food borne illnesses. During a review of the facility's P&P titled, Dietary Department, General, revised on 10/24/2023, the P&P indicated, food service staff must wear hairnets when cooking, preparing, or assembling food. 555616 Page 18 of 22 555616 12/19/2023 Ararat Post Acute 1230 E. Windsor Rd. Glendale, CA 91205

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 provide safe, and sanitary environment to help prevent the development and transmission of communicable diseases (one that is spread from one person to another through contact with blood and bodily fluids, or breathing in an airborne virus) for five of six sampled residents (Resident 19, 4, 13, 86 and 87) as indicated int facility's policy and procedure, titled Cleaning and disinfection (process of removing disease causing organism) of Resident Care Equipment. Residents Affected - Some The facility failed to: 1. Sanitize (disinfect something with a chemical, in order to destroy bacteria) the sphygmomanometer (BP [blood pressure] cuff-equipment used to measure blood pressure) cuff and the stethoscope (a medical device use for listening to the internal sounds of the human body) before and after used, between Resident 19 and Resident 4 as indicated in the facility's policy, 2. Sanitize the glucometer (a small, portable device that lets you check your blood sugars (glucose levels) for Resident 13 before and after each use. 3. Ensure Resident 86 and Resident 87's Nasal Cannula (NC) tubing (a plastic tubing used to deliver oxygen to the nares [opening in the nose]) was labeled with the date as indicated in the facility's policy and procedure Oxygen Administration. These deficient practices had the potential to result in cross contamination of disease-causing organisms (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and result in a widespread infection in the facility. Findings: 1. During a review of Resident 4's admission Record, indicated the facility admitted Resident 4 on 9/8/2022 with diagnoses that included hypertension (high blood pressure). During a review of Resident 4's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 8/1/2023, the MDS indicated Resident 4 required supervision with bed mobility (how resident moves to and from lying position), transfer, oral hygiene, toilet use and personal hygiene. During a medication pass observation, on 12/17/2023 at 8:16 am, the Licensed Vocational Nurse 2 (LVN 2) did not sanitize the BP cuff and the stethoscope (a device used to listen to the heartbeat or pulse and lung sounds) after using to check Resident 4's BP and pulse. During a medication pass observation, on 12/17/2023 at 8:52 am, the LVN 2 did not sanitize the BP cuff and the stethoscope before using for Resident 19. During a review of Resident 19's admission Record, indicated the facility admitted Resident 19 on 4/15/2022 with diagnoses that included hypertensive heart disease (a range of conditions that affect the heart) with heart failure (heart disease that affects pumping action of the heart muscle). 555616 Page 19 of 22 555616 12/19/2023 Ararat Post Acute 1230 E. Windsor Rd. Glendale, CA 91205

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 19's MDS, dated [DATE], the MDS indicated Resident 19 required extensive assistance with one person assist with bed mobility (how resident moves to and from lying position), transfer, oral hygiene, toilet use and personal hygiene. During an interview on 12/17/2023 at 8:53 am with the LVN 2, the LVN 2 stated all equipment should be sanitized before and after each residents use. The LVN 2 stated, it was important to sanitize equipment before and after using between residents to prevent the spread of infection. During an interview on 12/17/2023 at 10:07 am with the facility's Director of Nurses (DON), the DON stated the staff should disinfect or sanitize (clean something with a chemical to destroy bacteria) all equipment used in between residents. The DON stated, staff needed to disinfect or clean equipment before and after use to prevent cross contamination. 2. During a review of Resident 13's admission record indicated, the facility admitted Resident 13 on 4/14/2023 with diagnoses that included type 2 DM Diabetes Mellitus (a condition of having high blood sugar) and dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). During a review of Resident 13's Physician order, dated 10/19/2023, indicated to inject Basaglar Kwik Pen insulin (Insulin Glargine - long-acting insulin [a hormone that works by lowering levels of sugar in the blood]) 28 units subcutaneously (administering medication where a short needle is used to inject a medication into the tissue layer between the skin and the muscle) one time a day for type 2 DM. During a review of Resident 13's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/10/2023, the MDS indicated, Resident 13's cognition for daily decision making was intact. Resident 13 required moderated assistance with toileting, shower, and lower body dressing. During a medication pass observation on 12/17/2023 at 9:46 am, LVN 2 did not sanitize the glucometer prior to testing Resident 13's blood sugar level. LVN 2 stated, the glucometer should have been disinfected before and after use, to make sure it was clean, because there might be a splash of blood in the glucometer. During an interview on 12/17/2023 at 10:09 am with the facility's DON, the DON stated there might be a splash of blood in the glucometer if it was not disinfected before using. The DON stated, the staff needed to disinfect or clean equipment before and after use to prevent cross contamination. During a review of the facility's P&P titled, Cleaning and disinfection of Resident Care Equipment, revised on 5/1/2017, indicated reusable items (equipment that is designated reusable by more than one resident) are cleaned and disinfected or sterilized between residents (e.g., stethoscope, durable medical equipment). 3a. During a review of Resident 86's admission Record, indicated the facility admitted Resident 86 on 12/13/2023 with diagnoses that included acute respiratory failure (a condition in which not enough oxygen passes from the lungs into the blood) with hypoxia (low levels of oxygen in the body tissues). A review of Resident 86's Physician Order's, dated 12/13/2023, indicated to administer oxygen at two (2) liters per minute (L/min) via nasal cannula (a device with two prongs that sit below the nose 555616 Page 20 of 22 555616 12/19/2023 Ararat Post Acute 1230 E. Windsor Rd. Glendale, CA 91205

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some used to deliver supplemental oxygen directly into the nostrils) to keep oxygen saturation (a percent of blood cells carrying oxygen in the body) 90% and above every eight hours as needed. During a concurrent observation and interview on 12/15/2023, at 8:22 pm, with LVN 3, Resident 86 lying in bed with oxygen in use delivered at 2 LPM via nasal cannula with the tubing unlabeled without date of when it was last changed. LVN 3 stated the nasal cannula should be labeled when first used and if not in used the NC tubing should be placed in a bag with date labeled. LVN 3 stated, NC tubing should be dated for infection control. During an interview on 12/16/2023, at 12:50 pm, with the facility's DON, the DON stated, NC tubing should be labeled when first used and it should be placed inside the bag when not in used for infection control. During a review of the facility's policy and procedure titled, Oxygen Administration, revised on 8/1/2014, indicated, all oxygen tubing, humidifiers (a device used to make supplemental oxygen moist), masks and cannulas used to deliver oxygen will be changed weekly. 3b. During a review of Resident 87's admission record indicated, the facility admitted Resident 13 on 12/8/2023 with diagnoses that included type 2 DM and long-term use of insulin (a hormone that helps control your body's blood sugar level) use. During a review of Resident 87's History and Physical (H&P), dated 12/11/2023, indicated Resident 87 did not have the capacity to understand and make decisions. During a concurrent observation and interview on 12/15/2023, at 8:12 pm, with Director of Staff and Development (DSD), Resident 87 lying in bed with oxygen concentrator (a medical device that concentrates oxygen from environmental air and delivers it to the resident in need of supplemental oxygen) with a humidifier (a bottle connected to the oxygen concentrator used to moisten the air before breathing in via NC) that had no label of the date the humidifier was first used or when to be changed. The NC and the storage bag for the NC at the bedside did not have a label of the time it was first used and when to be change. During a concurrent observation and interview on 12/15/2023, at 8:31 pm, with the DSD, the DSD stated Resident 87's nasal cannula tubing should be labeled with date to know when it was replaced and first used for infection control. The DSD stated, the storage bag should be labeled with resident name and date to know that nasal cannula belonged to Resident 87. During an interview on 12/17/2023, at 10:30 am, with the facility's DON, the DON stated the nasal cannula tubing and the storage bag should be labeled to identify the equipment for infection control. During an interview on 12/17/2023, at 10:39 am, with the facility's Infection Prevention Nurse (IPN), the IPN stated the nasal cannula tubing and the storage bag belonged to Resident 87. The IPN stated she forgot to label the date in the nasal cannula and label the storage bag of Resident 87's name. IPN stated, nasal cannula tubing and storage bag should be dated and labeled with Resident 87's name for infection control. During a review of the facility's policy and procedure titled,Oxygen Administration), revised on 8/1/2014, indicated, for infection control all oxygen tubing, humidifiers, masks and cannulas used to 555616 Page 21 of 22 555616 12/19/2023 Ararat Post Acute 1230 E. Windsor Rd. Glendale, CA 91205

F 0880 deliver oxygen are for single resident used only. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 555616 Page 22 of 22