Health inspection·November 29, 2023

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to communicate with one of six sampled residents' (Resident 12) representative that Resident 12 was transferred to General Acute Care Hospital (GACH) intensive care unit (residents who are dangerously ill are kept under constant observation) due to labored breathing. This failure had the potential to result in Resident 12's representative being unaware of the residents' medical condition and status. Findings: During a review of Resident 12's admission Record (Face Sheet), the Face Sheet indicated Resident 12 was admitted to the facility on [DATE] and readmitted on [DATE]. Record indicated Resident 12's emergency contact was Family Member 1. During a review of Resident 12's History and Physical (H&P), dated 7/30/2023, the H&P indicated Resident 12's diagnoses included respiratory failure (when blood does not have enough oxygen), intracerebral brain hemorrhage ([ICH] bleeding in the brain), seizure disorder (a sudden, uncontrolled burst of electrical activity in the brain). The H&P indicated Resident 12 was clinically quadriplegic (not able to move all for extremities), aphasic dysphasia (affects the ability to produce and understand spoken language). During a review of Resident 12's Minimum Data Set ([MDS] a comprehensive assessment and care-screening tool), dated 11/19/2023, the MDS indicated Resident 12's cognition (ability to learn, reason, remember, understand, and make decisions) was persistent vegetative state (a chronic state of brain dysfunction in which a person shows no signs of awareness) and no discernible consciousness (ability to learn, reason, remember, understand, and make decisions). The MDS indicated Resident 12 was total dependent for activities of daily living ([ADL] activities related to personal care) when eating, oral hygiene, bathing, and toileting. During a concurrent interview and record review on 11/28/2023 at 2:32 p.m. with Director of Sub-Acute, Resident 12 Nursing Narrative Note, dated 6/13/2023 and the Discharge Summary dated 6/24/2023 was reviewed. The Nursing Narrative Note indicated, Resident 12 was hospitalized and sent to intensive care unit due to labored breathing on 6/13/2023 and there was no documentation the responsible party was notified. The Director of Sub-Acute stated the facility did not contact the resident representative by phone nor in writing to notify that Resident 12 went to the hospital. The Director of Sub-Acute was not able to locate documentation that Family Member 1 was notified of the transfer to the hospital. The Director of Sub-Acute stated it was important to notify the resident representative, so Page 1 of 9 555638 555638 11/29/2023 Los Angeles Comm Hospital 4081 East Olympic Blvd Los Angeles, CA 90023

F 0623 they will be aware of what was going on with the resident. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/29/2023 at 2:39 p.m. with Licensed Vocational Nurse (LVN) 2. LVN 2 stated if there was a change in condition, she would notify the charge nurse, and the charge nurse will call the doctor and notify the family regarding resident ' s change of condition. LVN 2 stated she was not able to locate a record the responsible party was notified Resident 12 was transferred to GACH on 6/13/2023. LVN 2 stated it was important to involve the family to let them know what was going on so they can be involve in the treatment plan. Residents Affected - Few During an interview on 11/29/2023 at 2:58 p.m. with Registered Nurse (RN) 1, RN 1 stated the process when there was a change of condition was to call the physician and to notify the family of the change in condition. RN 1 stated it was important to notify the family so the family would know what was going with the resident. During a review of the facility's Policy and Procedure (P&P) titled, Change in Resident Condition/Notification of Changes, date unknown, the P&P indicated, that all changes in resident condition and other changes , as required by regulations, will be communicated to the physician and family or psychosocial status .If unable to reach physician or family/legal representatives, the notifications, including calls to physicians or exchanges requesting callbacks, will be documented on the Nursing Narrative notes .If a decision to transfer or discharge a resident is made, the charge nurse will notify the family or legal representative promptly 555638 Page 2 of 9 555638 11/29/2023 Los Angeles Comm Hospital 4081 East Olympic Blvd Los Angeles, CA 90023

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to clarify the physician order for the administration route of Pioglitazone (medication to treat high blood sugar levels) for one of seven sampled residents (Resident 27). Residents Affected - Few This failure placed Resident 27 at risk for aspiration due to inability to swallow medications. Findings: During a review of Resident 27's admission Record (face sheet), the face sheet indicated Resident 27 was admitted to the sub-acute on 8/25/2023. Resident 27 ' s diagnoses included hypertension (the pressure in the blood vessels is too high) metabolic syndrome (a cluster of conditions that increase the risk of heart disease), respiratory failure (the blood does not have enough oxygen), tracheostomy (an incision to relieve an obstruction to breathing). During a review of Resident 27's History and Physical (H&P), dated 8/25/2023, the H&P indicated, Resident 27 was alert and oriented and able to verbalize wishes. During a review of Resident 27's Minimum Data Set ([MDS] a comprehensive assessment and care-screening tool), dated 8/29/2023, the MDS indicated Resident 27 ' s cognition (ability to learn, reason, remember, understand, and make decisions) was intact and required maximal assistance for eating. During a concurrent interview, and record review on 11/28/2023 at 8:25 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 27's Patient Orders (Physician Orders) dated 11/28/2023 was reviewed. LVN 1 stated the order indicated Resident 27 was to receive Pioglitazone 30 mg one tablet by mouth daily. LVN 1 stated Resident 27 cannot swallow pills at this time, and she should use the gastrostomy tube ([G-tube] is a tube inserted through the belly that brings nutrition directly to the stomach) to administer the medication. During a concurrent observation and interview on 11/28/2023 at 8:40 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 was observed crushing and administered Pioglitazone 30 mg to Resident 27 via G-tube. LVN 1 stated Resident 27 cannot swallow pills at this time, and she should use the G-tube to administer the medication. During a concurrent interview and record review on 11/29/2023 at 2:45 p.m. with LVN 2, Resident 27's Patient Orders (Physician Orders), dated 11/7/2023 was reviewed. LVN 2 stated the order indicated, Pioglitazone 30 mg oral daily. LVN 2 stated she administered the Pioglitazone 30 mg via G-tube. LVN 2 stated Resident 27 was not able to swallow pills and the medications should be given via G-tube. LVN 2 stated the nurses should notify the physician that Resident 27 was unable to swallow pill and get clarification that medication should be administered via G-tube. LVN 2 stated they should not give the medication until the medication was clarified. LVN 2 stated it was important to get clarification of the order to avoid Resident 27 from choking on the tablet. LVN 2 stated she or Registered (RN) 1 should have obtained the correct order and should have verified the correct route for the medications because Resident 27 could not swallow pills. During a concurrent interview and record review on 11/29/2023 at 2:58 p.m. with LVN 2, Resident 27's Patient Orders, dated 11/7/2023 was reviewed. The Patient Order indicated Pioglitazone 30 mg oral to be given daily. RN 1 stated Resident 27 cannot swallow pill and was being given medications via 555638 Page 3 of 9 555638 11/29/2023 Los Angeles Comm Hospital 4081 East Olympic Blvd Los Angeles, CA 90023

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few G-tube. RN 1 stated the LVNs failed to get clarification of the order and should have the medication route switched from oral to G-tube. RN 1 stated the LVNs should have reported these concerns to the RNs. RN 1 stated Resident 27 was at risk for aspiration, and the discrepancy should have been reported to her. During a concurrent interview and record review on 11/29/2023 at 5:22 p.m. with the Director of Sub-Acute, Resident 27's Patient Orders, dated 11/7/2023 was reviewed. The Director of Sub-Acute stated Resident 27 had trouble with swallowing, and the physician order indicated to give Pioglitazone 30 mg daily via mouth. The Director of Sub-Acute stated they should not give the medication when there was a discrepancy on the physician order and should have clarified the order to the physician first. The Director of Sub-Acute stated Resident 27 should have not received the medication until the order was clarified. The Director of Sub-Acute stated it was important to clarify the order from the physician because the wrong order can potentially harm Resident 27 since he has trouble swallowing. During a review of the facility's policy and procedure titled, Preparation and Administration of Medications, dated 2/2021, the P&P indicated, To facilitate the safe, effective, and accurate dispensing, administration, and monitoring of medication by qualified members of the hospital .the order shall include the route of administration .When a patient unable to swallow a prescribed tablet notify the pharmacy .The pharmacist or RN may contact the physician for more appropriate medication if an equivalent alternative is not available. 555638 Page 4 of 9 555638 11/29/2023 Los Angeles Comm Hospital 4081 East Olympic Blvd Los Angeles, CA 90023

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to remove expired insulin (medication used to regulates the amount of glucose in the blood) vials for three of six residents (Residents 25, 27, and 30) receiving insulin. This deficient practice placed the residents at risk for not receiving the proper strength of insulin doses. Findings: During a concurrent observation, interview, and record review on 11/29/2023 at 5:00 p.m., with the Director of the Sub-Acute unit, in Medication Cart 4 there were three vials of expired insulin. The three insulin vials expired more than 28 days ago. The insulin vials included: 1. Glargine (medication used to reduced blood sugar level) had labeled opened date 10/31/2023 and expiration date of 11/28/2023. 2. Lispro (medication used to reduced blood sugar) had labeled opened date 10/31/2023 and an expiration date on 11/28/2023. 3. Lispro labeled opened date 10/26/2023 and an expiration date on 11/23/2023. The Director of the Sub-Acute unit stated once an insulin vial was opened the opened and expired dates were placed on the vial. Once opened the vials are only good for 28 days. The Director of the Sub-Acute stated the nursing practice was to check at the beginning of the shift to see if there were any expired medications. The Director of the Sub-Acute also stated, the facility failed to check and see if there were expired medications. Administrating insulin after the expiration date could influence the potency (strength) of the medication resulting in the resident not receiving the correct dose. During an interview on 11/30/2023 at 8:47 a.m., Licensed Vocational Nurse (LVN) 3, stated once the insulin vial was opened it was only good for 28 days. LVN 3 stated after opening the insulin vial, she placed an opened date label on the insulin vial and an expiration date of 28 days. LVN 3 also stated before administrating the medication she will look to see if the medication was expired. If the medication was expired, she would not administer the medication because the chemical components in the insulin can influence the effect on the resident. The insulin can either make the resident hypoglycemic (low blood sugar level) or hyperglycemic (high blood sugar level) due to the changing chemical strength of the insulin. During an interview on 11/30/2023 at 8:53 a.m., Registered Nurse (RN) 1 stated, insulin when opened should have an open date and an expiration date of 28 days. RN 1 also stated before giving insulin to the residents the dates need to be checked. If the insulin vial was expired the medication needs to be pulled from the medication cart and disposed. It was important to be aware of the expiration dates so the medication will not have an effect and will be more efficient for the residents. RN 1 stated if the expired medication was administered the medication may be less potent after 28 days. 555638 Page 5 of 9 555638 11/29/2023 Los Angeles Comm Hospital 4081 East Olympic Blvd Los Angeles, CA 90023

F 0761 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's Policy and Procedure (P&P) titled, Expiration Date, dated 8/2023, the P&P indicated, Expiration dates shall be used on medications dispensed to the patients .The expiration date refers to the date beyond which the drug may lose it effectiveness and should not be dispensed or administered to a patient .The expiration date assigned to opened multiple dose vials is twenty-eight days, or manufacturer's guidelines. Residents Affected - Some 555638 Page 6 of 9 555638 11/29/2023 Los Angeles Comm Hospital 4081 East Olympic Blvd Los Angeles, CA 90023

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 ensure Licensed Vocational Nurse (LVN) 2 performed hand hygiene during a wound dressing change for one of four Residents (Resident 19). Residents Affected - Few This deficient practice placed Resident 19 at increased risk of contamination of the sacral (near the lower back and spine) wound during a dressing change. Findings: During a review of Resident 19's admission Record (Face Sheet), the Face Sheet indicated Resident 19 was admitted to the facility on [DATE]. During a review of Resident 19's History and Physical (H&P), dated 7/12/2023, the H&P indicated Resident 19's diagnoses included respiratory failure (when blood does not have enough oxygen), sepsis (the body's extreme response to an infection). The H&P indicated Resident 19 was clinically quadriplegic (not able to move all for extremities). During a review of Resident 19's Minimum Data Set ([MDS] a comprehensive assessment and care-screening tool), dated 8/29/2023, the MDS indicated Resident 19's cognition (ability to learn, reason, remember, understand, and make decisions) was sometimes understood and ability was limited to making concrete request. The MDS indicated Resident 19 was total dependent for activities of daily living ([ADL] activities related to personal care) when eating, oral hygiene, bathing, and toileting. During an observation on 11/29/2023 at 2:16 p.m. in Resident 19's room, LVN 2 was observed changing a dressing to the sacral wound (skin injuries that occur in the region of the body, near the lower back and spine). LVN 2 removed the soiled dressing from sacral wound and the wound had visible copious (liquid or discharge those oozes from a wound) drainage on dressing. LVN 2 removed soiled gloves and put on new gloves without performing hand hygiene and continued to touch the wound and performed wound care. During an interview on 11/29/2023 at 3:00 p.m., LVN 2 stated she did not wash her hands or used hand sanitizer after touching soiled dressing with drainage from the sacral wound. LVN 2 stated she should wash her hands after removing the soiled gloves with soap and water. LVN 2 stated after removing the soiled dressings and touching contaminated items, she should have washed her hands before continuing performing wound care. LVN 2 stated she thought her hands were not considered soiled because she cleaned and sanitized her hands before the wound treatment. LVN 2 stated since she did not wash her hands after removing the soiled gloves and touching contaminated items, she put the resident at risk for bacteria cross contamination and it could affect the sacral wound healing. During an interview on 11/29/2023 at 3:13 p.m. with Registered Nurse (RN) 1. RN 1 stated even if the staff were wearing gloves during a wound care, the hands should be washed after touching contaminated or dirty items because the hands were dirty from touching the soiled dressing. RN 1 stated when hand washing was not done after removing soiled dressing, bacteria could be introduced to the wound and put the resident at risk for infection. During an interview on 11/29/2023 at 3:30 p.m. with the Director of Sub-Acute. The Director of Sub-Acute stated when the soiled dressing was removed, we take off the soiled gloves and put the soiled 555638 Page 7 of 9 555638 11/29/2023 Los Angeles Comm Hospital 4081 East Olympic Blvd Los Angeles, CA 90023

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few items in the trash including the gloves. The Director of Sub-Acute stated the next was to wash hands after removing soiled gloves and put on clean gloves. The Director of Sub-Acute stated LVN 2 did not use clean technique when doing the dressing change for Resident 19 and exposed Resident 19 for risk of potential infection to the open wound and the wound could get worse. During a review of the facility's Policy and Procedure (P&P) titled, Hand Hygiene, dated 2/2019, the P&P indicated, When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or body fluids, wash hands with either non-antimicrobial or microbial soap, and water. During a review of the facility's Policy and Procedure (P&P) titled, Dressing-Sterile/Non-Sterile, dated 10/2022, the P&P indicated, To provide cleanliness to prevent infection, to provide protection to the skin surface, and to promote resident comfort and wound healing .For Non-Sterile dressings remove and [NAME] nonsterile disposable gloves in plastic bag at bedside .Wash hands thoroughly. 555638 Page 8 of 9 555638 11/29/2023 Los Angeles Comm Hospital 4081 East Olympic Blvd Los Angeles, CA 90023

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of one resident rooms (Rooms # 16) met the requirements of 80 square feet (sq. ft.) for each resident. This deficient practice had the potential to result in an inadequate provision of safe nursing care, and privacy for the residents. Findings: During a record review on 11/27/23 at 9:44 a.m., the Administrator (ADM) provided a copy of the facilities annual request for waiver letter. A review of the letter indicated there are 12 resident room with less than the required 80 sq. ft. per resident, and the rooms are monitored to ensure that furnishing and equipment in the room does not hamper provision of needed care and there is sufficient space to meet the needs of both residents. ADM stated the facility would be requesting a room waiver for 2024. According to the Client Accommodations Analysis form, dated 12/13/2016, the facility had room [ROOM NUMBER] that measured less than 199 sq. ft. per resident. However the accurate room measurement was as follow: room [ROOM NUMBER] (2 beds) 158.05 sq. ft. During observations, from 11/27/23 - 11/30/23, the residents residing in these rooms had enough space to move freely inside the rooms. Each resident in the above rooms had beds and side tables with drawers. There was adequate room for the operation and use of wheelchairs, walkers, or canes. Room size did not affect the nursing care or privacy provided to the residents. 555638 Page 9 of 9