Health inspection·November 22, 2023

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based in interview and record review, three of four sampled staff (Pharmacy Technician 1[PTech 1], Licensed Vocational Nurse 1 [LVN 1] and Registered Nurse 1 [RN 1]) did not know to report allegation of abuse to the state agency as indicated in the facility's Policy and Procedure titled Elder and Dependent Adult Abuse. Residents Affected - Some This deficient practice had the potential for employees not to report an abuse incident to the state agency, which could lead to possible harm and risk of further abuse of the residents. Findings: During an interview on 11/21/2023 at 9:31 am, with PTech 1, PTech 1 stated she worked full time for 30 years in the facility. PTech 1 stated she was a mandated reporter and she had to report to Ombudsman if an abuse was witnessed in the facility. RN 1 stated she did not remember that she needed to report any kind of abuse to the State Agency or California Department of Public Health (CDPH) and local law enforcement agency. PTech 1 stated it was important to report to CDPH and enforcement agency because they investigate abuse cases. During an interview on 11/21/2023 at 9:40 am, with LVN 1, LVN 1 stated, she worked full time for one year in the facility. LVN 1 stated she was a mandated reporter. LVN 1 stated she could not remember who else to report abuse aside from the Ombudsman. LVN 1 stated it was important to report to CDPH and law enforcement agency because they were the ones who investigate abuse cases. During an interview on 11/21/2023 at 9:48 am, with RN 1, RN 1 stated, she worked full time for 20 years in the facility. RN 1 stated she was a mandated reporter and should report alleged abuse immediately to the Ombudsman. RN 1 stated she could not remember what other agency to report abuse. RN 1 stated it was important to report to CDPH and law enforcement agency because they investigate abuse cases. During an interview on 11/21/2023 at 2:49 pm with Director of Nursing (DON), the DON stated it was the facility's policy that all staff should report any kind of abuse to the Ombudsman, local law enforcement and CDPH. The DON stated it was important to notify the stage agency, CDPH and ombudsman for any kind of abuse in the facility because they conduct abuse investigations. During a review of the facility's Policy and Procedure (P&P) titled, Abuse, Elder and Dependent Adult revised on 1/13/2022, the P&P, indicated, when an incident of abuse or neglect is alleged or suspected to have occurred in a long-term care facility, the report is made to the Long-Term Care Ombudsman Program and to the local law enforcement agency. The Department of Health is also to be notified. The P&P indicated, if the suspected abuse occurs in a long-term care unit, the mandated reporter Page 1 of 21 555649 555649 11/22/2023 West Covina Medical Center D/P Snf 725 S. Orange Avenue West Covina, CA 91790

F 0607 must report the incident by telephone within 24 hours to local law enforcement agency and provide a written report to the local Ombudsman and local law enforcement agency. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 555649 Page 2 of 21 555649 11/22/2023 West Covina Medical Center D/P Snf 725 S. Orange Avenue West Covina, CA 91790

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** b. During a review of Resident 1's admission record, the admission record indicated the facility admitted Resident 1 on 4/22/2022 with diagnoses that included elevated white blood cell count (WBC - part of body's immune system that helps to fight infection), 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 1's MDS dated [DATE], the MDS indicated, Resident 1's cognition for daily decision making was severely impaired. The MDS indicated Resident 1 required total dependence with two-person physical assistance with bed mobility, transfer (how resident moves between surfaces including to or from bed, chair, wheelchair, standing position), dressing, and toilet use. During a review of Resident 1's Physician order, dated 6/15/2022, the physician's order indicated to give Resident 1 Lorazepam (antianxiety [medication to treat anxiety [emotion characterized by feelings of tension, worried thoughts and physical changes]), one (1) milligrams (mg), 1 tablet via gastrostomy tube (GT- a tube inserted through the abdomen that delivers nutrition/medication directly to the stomach) every two hours, as needed for jerking (not for psychotropic [any medication capable of affecting the mind, emotions, and behavior] use). During a concurrent interview and record review on 11/20/2023 at 4:10 pm, with the Assistant Director of Nursing (ADON), Resident 1's medical record was reviewed. The ADON stated a care plan was not developed to address interventions for Resident 1 with behavior of jerking. The ADON stated there was no other clinical documentation that a care plan was developed for Resident 1 to address jerking. The ADON stated, a care plan needed to be developed and interventions should have been implemented to address Resident 1's behavior of jerking. During an interview and concurrent record review on 11/21/2023 at 3:04 pm, with the Director of Nursing (DON), the DON stated a care plan to address Resident 1's behavior of jerking needed to be developed for the staff to know the interventions and necessary treatment the resident needed. During a review of the facility's Policy and Procedure (P&P) titled, Care Planning, reviewed 1/13/2023, the P&P indicated, The purpose of care planning was to improve patient care by identifying significant patient problems. To place this information in a suitable form and kept it in a central location to be utilized by all nursing and ancillary staff. Care plans will be initiated at the time of assessment by the admitting RN. Care plans shall be reviewed quarterly and revised PRN. Based on interview and record review, the facility failed to develop a specific and individualized person-centered care plan (a care plan details why a person is receiving care, assessed health or care needs, medical history, personal details, expected and aimed outcomes, and what care and support will be delivered, how, when and by whom) to meet the resident's needs for three of three sampled residents (Resident 1, Resident 7, and Resident 22). a. A care plan was not developed for Resident 7 with elevated Blood Urea Nitrogen (BUN, the test measures the amount of waste product in the blood from the kidney) and was on Intravenous Fluid (IVF, liquids injected straight into a person's vein to prevent or treat dehydration and electrolyte imbalances) therapy for hydration. 555649 Page 3 of 21 555649 11/22/2023 West Covina Medical Center D/P Snf 725 S. Orange Avenue West Covina, CA 91790

F 0656 Level of Harm - Minimal harm or potential for actual harm b. A care plan was not developed for Resident 1 to address interventions for behavior of jerking as a target behavior for the use of Lorazepam (antianxiety medication). c. A care plan was not developed for Resident 22 with foley catheter (a soft, plastic or rubber tube that is inserted into the bladder to drain the urine). Residents Affected - Some These failures had the potential to result in inconsistent implementation of the care plan that may lead to a delay or lack of delivery of care and services for Residents 1,7, and 22. Findings: a. During a review of Resident 7's Face Sheet (FS), the FS indicated, Resident 7 was readmitted to the facility on [DATE] with diagnoses that included enterocolitis due to clostridium difficile (inflammation of the colon that results from the disruption of normal healthy bacteria in the colon) and benign prostatic hyperplasia (age-associated prostate gland enlargement that can cause difficulty in urination). During a review of Resident 7's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 8/29/2023, the MDS indicated Resident 7 had both bladder and bowel incontinence (lack of voluntary control over urination or defecation). During a review of Resident 7's Laboratory Report (LR), dated 11/13/2023, the LR indicated Resident 7 had an elevated BUN result of 70 milligrams per deciliter (mg/dl) with normal reference range of 7-20 mg/dl. During a review of Resident 7's Physician's Orders (PO), dated 11/13/2023, the PO indicated Resident 7 had an order of Half (½) Normal Saline (a half-strength normal saline solution indicated for the treatment of dehydration or hypervolemia) at 50 milliliter per hour (ml/hr.) for BUN of 70. During a concurrent interview and record review on 11/20/2023 at 2:51 pm with Registered Nurse Supervisor 1 (RN Sup 1), Resident 7's LR and PO were reviewed. The LR for Resident 7 indicated BUN was elevated. The PO for Resident 7 indicated an order of IVF therapy for BUN of 70. RN Sup 1 stated a care plan was not developed to address interventions for Resident 7 with elevated BUN and on IVF therapy. RN Sup 1 stated, there was no other documented evidence that care plan was developed to address Resident 7's elevated BUN and IVF therapy. RN Sup 1 stated, a care plan should be developed every time there was a change of condition and new orders to monitor if interventions were effective for the resident. During a concurrent interview and record review of Resident 7's clinical record on 11/20/2023 at 3:11 pm with the Assistant Director of Nursing (ADON), the ADON stated, there was no documentation that a care plan was developed to address and monitor the interventions for Resident 7 with elevated BUN and on IVF therapy. During an interview on 11/21/2023 at 2:54 pm with the Director of Nursing (DON), the DON stated a care plan needed to be developed for Resident 7 for the staff to know the interventions and treatment Resident 7 needed and to monitor if Resident 7 was improving or not. During a review of the facility's Policy and Procedure (P&P) titled, Care Planning, dated 1/13/2023, the P&P indicated, The purpose of care planning was to improve patient care by identifying 555649 Page 4 of 21 555649 11/22/2023 West Covina Medical Center D/P Snf 725 S. Orange Avenue West Covina, CA 91790

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some significant patient problems. To place this information in a suitable form and kept it in a central location to be utilized by all nursing and ancillary staff. Care plans will be initiated at the time of assessment by the admitting RN. Care plans shall be reviewed quarterly and revised PRN. c. During a review of Resident 22's Face Sheet, the face sheet indicated Resident 22 was admitted on [DATE], with diagnoses that included neuromuscular dysfunction of the bladder (the nerves and muscles don't work together very well causing the bladder not filled or empty correctly) and dependence on respirator (ventilator, a mechanical device that enables the delivery or movement of air and oxygen into the lungs of a patient whose breathing has ceased, is failing, or inadequate). During a review of Resident 22's MDS dated [DATE], the MDS indicated Resident 22 had unclear speech, rarely/never understood others, and rarely/never made self-understood. Resident 22 was totally dependent (helper does all the effort and resident does none of the effort to complete the activity) for oral hygiene and toileting. The MDS indicated Resident 22 had an indwelling catheter (foley catheter). During a review of Resident 22's Physician Orders for 11/2023, the physician's order indicated Resident 22 was ordered on 10/25/23 foley catheter for neurogenic bladder (lack of bladder control due to a brain, spinal cord, or nerve problem.) During an observation on 11/20/2023, at 9:08 am, Resident 22 was lying in bed. Resident 22 had foley catheter hanging at bed frame. During a concurrent interview and record review of Resident 22's clinical record on 11/20/2023 at 3:24 pm, the Director of Nursing (DON) stated there was no care plan developed to address Resident 22's use of foley catheter. The DON stated the facility needed to develop a care plan for Resident 22 using foley catheter so that staff know the proper care of a resident with foley catheter and be able to identify sign and symptoms to report for any urinary tract infection (UTI- an infection in any part of the urinary system). The DON stated Resident 22 had history of UTI and residents (in general) on foley catheter had the potential to develop UTI. During a review of the facility's Policy and Procedure (P&P) titled, Care Planning, reviewed 1/13/2023, the P&P indicated To improve patient care by identifying significant patient problems. Care plans will be initiated at the time of assessment by the admitting Registered Nurse (RN). 555649 Page 5 of 21 555649 11/22/2023 West Covina Medical Center D/P Snf 725 S. Orange Avenue West Covina, CA 91790

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assess and monitor the presence of white sediments (visible particles in the urine that may contain red or white blood cells, casts, bacteria, fungi, parasites in the urine that could indicate infection or dehydration [fluid deficit]) in the urine for two of two sampled residents (Residents 8 and 22 ) with indwelling catheter (foley catheter - a tube inserted in the bladder to drain urine into a drainage bag), as indicated in the facility's Policy and Procedure, titled Urinary Catheter, Insertion and Care and the resident's care plan for foley catheter. This deficient practice had the potential for Residents 8 and 22 to receive no care or delayed care and treatment for urinary tract infection (UTI, condition in which bacteria invade and grow in any part the urinary system). Findings: a. During a review of Resident 22's Face Sheet, the face sheet indicated Resident 22 was admitted on [DATE], with diagnoses that included neuromuscular dysfunction of bladder (the nerves and muscles don't work together very well causing the bladder to not fill or empty correctly) and dependence on respirator (ventilator, a mechanized device that enables the delivery or movement of air and oxygen into the lungs of a patient whose breathing has ceased, is failing, or is inadequate). During a review of Resident 22's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 11/7/2023, the MDS indicated Resident 22 had unclear speech, rarely/never understood others, and rarely/never made self-understood. Resident 22 was dependent (helper does all of the effort; resident does none of the effort to complete the activity) for oral hygiene and toileting hygiene. The MDS indicated Resident 22 had an indwelling catheter (foley catheter). During a review of Resident 22's Physician Orders for 11/2023, the physician's order indicated Resident 22 was ordered foley catheter on 10/25/23 for neurogenic bladder (lack of bladder control due to a brain, spinal cord, or nerve problem.) During an observation on 11/20/2023, at 9:08 am, Resident 22 was lying in bed. Resident 22 had foley catheter hanging by the bed frame. Resident 22's foley catheter tube and urinary collecting bag had white sediments in it. During an interview on 11/20/2023, at 2:52 pm, Certified Nursing Assistant 2 (CNA 2) stated, she did not pay attention if there was sediment inside Resident 22's urinary tube and bag this morning when she emptied it. After surveyor showed the photo of Resident 22's urinary tube and bag taken this morning, CNA2 stated, the photo indicated there was sediment inside Resident 22's urinary tube and bag. CNA 2 stated she needed to report to the Charge Nurse the presence of sediments because this might be a sign of UTI. CNA 2 stated she needed to report the urine amount, color, odor, and sediments found in the urinary tube/bag of Resident 22 to the Charge Nurse each time she emptied Resident 22's urinary bag to prevent UTI. During an interview on 11/20/2023 at 3:17 pm, Licensed Vocational Nurse 4 (LVN 4) stated, she did not receive report from CNA 2 regarding urine sediments in Resident 22's urinary bag. LVN 4 stated 555649 Page 6 of 21 555649 11/22/2023 West Covina Medical Center D/P Snf 725 S. Orange Avenue West Covina, CA 91790

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 22 had history of UTI and should be monitored for urine abnormalities including sediments, color, and odor. LVN 4 stated any urine abnormalities should be documented and reported to the physician. LVN 4 stated Resident 22 will develop sepsis (severe infection) if urinary infection was not treated. During a review of the facility's Policy and Procedure titled, Urinary Catheter, Insertion and Care, reviewed 4/20/2023, the P&P indicated Any abnormalities observed in the urine must be documented and the physician notified i.e., presence of sediment, blood, strong odor, color, if cloudy or any other observation seen. b. During a review of Resident 8's admission record, the admission record indicated the facility admitted Resident 8 on 12/27/2022 with diagnoses that included postprocedural (after a procedure) complications and disorders of genitourinary (reproductive and urinary) systems and sepsis. During a review of Resident 8's Physicians Orders, dated 3/2/2023, the physician order indicated to insert foley catheter to Resident 8 for urinary retention. During a review of Resident 8's Care Plan titled, Resident Care Plan for Foley Catheter, initiated on 3/23/2023, the care plan indicated Resident 8 had foley catheter due to neurogenic bladder (bladder does not empty or store urine properly due to neurological condition). The plan of care indicated Resident 8 was at risk for UTI due to foley catheter use. The care plan interventions included for the nursing staff to monitor for signs/symptoms of infection such as fever, pain, burning, or sediments in foley bag and notify physician. During a review of Resident 8's MDS dated [DATE], the MDS indicated Resident 8's cognition (ability to understand) for daily decision making was severely impaired. The MDS indicated Resident 1 required total dependence with two-person physical assistance with bed mobility, transfer (how resident moves between surfaces including to or from bed, chair, wheelchair, standing position), dressing, toilet use and personal hygiene. During an observation on 10/20/2023 at 9:09 am, Resident 8 was asleep in bed. Resident 8 had foley catheter hanging at the left side of the resident's bed frame. Resident 8's foley catheter tubing had white sediments. During an interview on 10/20/2023 at 10:47 am. with Director of Nursing (DON), the DON stated the licensed nurses were monitoring the foley catheter every 8 hours to check for presence of blood or sediments, characteristics of the urine and signs and symptoms of UTI. The DON stated, there was no clinical documentation in Resident 8's clinical records that indicated the resident's urine was monitored for presence of white sediments and signs and symptoms of UTI. During a review of the facility's P&P titled, Urinary Catheter, Insertion and Care, reviewed 4/20/2023, the P&P indicated, any abnormalities observed in the urine must be documented and the physician notified that is presence of sediment, blood, strong odor, color if cloudy or any other observation seen. 555649 Page 7 of 21 555649 11/22/2023 West Covina Medical Center D/P Snf 725 S. Orange Avenue West Covina, CA 91790

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide necessary care and services for gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition directly to the stomach) feeding as ordered by the physician and as indicated in the facility's Policy and Procedure (P&P) and plan of care for two of five sampled residents (Residents 11 and 12) by failing to: a. Ensure Resident 11 received the recommended tube feeding formula and amount of gastrostomy tube feeding. b. Ensure to apply drain sponge to the gastrostomy site and anchor the gastrostomy tube of Resident 12. These failures had the potential for complications related to tube feedings for Residents 11 and 12. Findings: a. During a review of Resident 11's Face Sheet, the face sheet indicated Resident 11 was readmitted to the facility on [DATE] with diagnoses that included dependence on ventilator (a machine that support or replace the breathing of an ill or injured person) and dysphagia (difficulty swallowing). During a review of Resident 11's Care Plan (CP) dated 8/31/2023, the CP indicated Resident 11 had a potential for malnutrition and nutritional imbalance secondary to receiving tube feeding secondary to dysphagia. The CP had an approach plan that included to give GT formula as ordered, monitor tolerance to diet and to provide GT feeding as ordered. During a review of Resident 11's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 10/24/2023, the MDS indicated Resident 11 was on feeding tube for nutrition. During a review of Resident 11's Monthly Nutritional Review (MNR) dated 11/1/2023, the MNR indicated Resident 11 had a low phosphorous (a mineral the body needs to build strong bones and teeth) level and elevated blood urea nitrogen (BUN, the test that measures the amount of urea nitrogen in the blood which is a waste product that the kidneys remove from the blood). The MNR indicated, the Dietary Supervisor (DS) recommended Vital 1.0 (nutrition formula that provides a complete and balanced nutrition) at 50 milliliter/hour (ml/hr., flow rate). During a concurrent observation and interview on 11/20/2023 at 9:30 am with Licensed Vocational Nurse 3 (LVN 3) inside Resident 11's room, Resident 11 had an ongoing feeding formula of Peptamen (a specialized enteral nutrition formula) running at 40 ml/hr. LVN 3 stated, the Peptamen bag had Resident 11's name, rate, and time of 0400. LVN 3 stated the Peptamen bag had no date when it was changed nor started. LVN 3 stated, the feeding formula bottle or bag needed to have the resident's name, date, and time when it was started to determine when to change the formula. LVN 3 stated feeding formula should be changed every 24 hours. During a concurrent interview and record review on 11/20/2023 at 3:28 pm with the Assistant Director of Nursing (ADON), Resident 11's Physician's Order (PO) was reviewed. The PO indicated on 555649 Page 8 of 21 555649 11/22/2023 West Covina Medical Center D/P Snf 725 S. Orange Avenue West Covina, CA 91790

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 10/9/2023, Resident 11 had an order of Vital 1.0 at 50 ml/hr. The ADON stated Vital 1.0 can be replaced with Peptamen but needed clarification and approval with the dietitian and attending physician. The ADON stated the feeding formula order and rate needed to be clarified with the attending physician. The ADON stated there was no clinical record indicating the order and rate were clarified with the dietitian and attending physician. The ADON stated feeding formula bag or bottle should have the resident's name, rate, date, and time when it was changed. ADON stated feeding formula should be changed every 24 hours because the formula might get spoiled, and the resident might get sick receiving from it. During an interview on 11/22/2023 at 10:52 am with Registered Nurse Supervisor 1 (RN Sup 1), RN Sup 1 stated it was important to clarify the order of the feeding formula and rate with the dietitian to make sure the formula was appropriate to the resident. During a concurrent interview and record review on 11/22/2023 at 11:33 am with the Dietary Supervisor (DS), Resident 11's PO was reviewed. The PO indicated, on 10/4/2023, the Registered Dietitian (RD) recommended Vital HP (high protein, specialized therapeutic nutrition formula) at 50 ml/hr. The DS stated Vital HP was recommended because Resident 11 had low phosphorous level. The PO indicated, on 10/6/2023, Vital HP was not available and discontinued. The RD recommended feeding formula of Peptamen AF (peptide-based, high-protein formula) at 50 ml/hr. The PO indicated, on 10/9/2023, Peptamen was discontinued. Resident 11 had a new order and RD recommendation of Vital 1.0 at 50 ml/hr via GT. The DS stated, DS was not notified that Vital 1.0 was replaced with Peptamen. DS stated there was no order of reducing the rate of feeding from 50 ml/hr to 40 ml/hr. The DS stated giving a different formula and amount will result to weight loss and electrolyte imbalance (too much or not enough of certain minerals in the body). During a review of the facility's Policy and Procedure (P&P) titled, Feeding, Enteral Tube and Pump, dated 4/20/2023, the P&P indicated, Label on the container must state the patient's name, date, feeding name, strength (if full strength is not used) rate and time hung. All tube feedings, when open are to be discarded after 24 hours. Any recommendations as to the adequacy and appropriateness of the enteral feeding are made by the dietitian to the Physician. The appropriateness of enteral nutrition usage will be monitored jointly by Dietary and Pharmacy through the use of approved usage criteria monitoring forms. b. During a review of Resident 12's Face Sheet, the face sheet indicated Resident 12 was readmitted to the facility on [DATE] with diagnoses that included diabetes mellitus (elevated blood sugar level) and dysphagia (difficulty swallowing). During a review of Resident 12's Care Plan (CP) dated 7/17/2023, the CP indicated Resident 12 was at risk for irritation/infection or further irritation/infection on around the g-tube site. The CP had an approach plan that included cleanse GT site daily and as needed (PRN) and to check GT site dressing every shift and as needed for soilage, leaking, or staining. During a review of Resident 12's MDS dated [DATE], the MDS indicated, Resident 12 was on feeding tube for nutrition. During a review of Resident 12's Physician Orders (PO) for November 2023, the PO indicated on 4/12/21, Resident 12 had an order of gastrostomy care with ½ strength H202 (hydrogen peroxide) plus normal saline (NS), pat dry and apply drain sponge every shift. 555649 Page 9 of 21 555649 11/22/2023 West Covina Medical Center D/P Snf 725 S. Orange Avenue West Covina, CA 91790

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 12's Treatment Administrative Record (TAR) for November 2023, the TAR indicated Resident 12 had gastrostomy care done and gastrostomy site had drain sponge applied every shift. During a concurrent observation and interview on 11/20/2023 at 9:15 am with Licensed Vocational Nurse (LVN) 3 inside Resident 12's room, Resident 12's GT site did not have a drain sponge dressing applied and was not secured. LVN 3 stated, Resident 12's GT site needed to have a drain sponge dressing applied and secured with tape to prevent from tugging and pulling and to prevent infection. During an interview on 11/20/2023 at 2:05 pm with Registered Nurse Supervisor 1 (RN Sup1), RN Sup 1 stated, Resident 12's GT site needed to have a drain sponge dressing and secured with tape to absorb any drainage or leakage and prevent the gastrostomy tube from irritating Resident 12's skin around the GT site. During a review of the facility's P&P titled, Gastrostomy and PEG Tube Care of And Changing, dated 4/20/2023, the P&P indicated, Assess site for signs and symptoms of infection or excessive granulation formation. For PEG tube, ensure that the disc is aligned next to the skin, without pressure into the skin. Note the distance of the tube from adapter to entrance into the skin, this helps evaluate whether tube has migrated inward or pulled outward. Apply a 4 x 4 split gauze pad around the tube, and secure with paper tape. 555649 Page 10 of 21 555649 11/22/2023 West Covina Medical Center D/P Snf 725 S. Orange Avenue West Covina, CA 91790

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. 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 label and date intravenous catheter (IV, a thin plastic tube inserted into a vein using a needle allowing for the administration of medications, fluids and/or blood products.) for three out of three sampled residents (Resident 21, 20 and 7). Residents Affected - Some These failures had the potential to result in infection to the residents and worsen the residents' health condition. Findings: a. During a review of Resident 21's Face Sheet, the face sheet indicated Resident 21 was admitted on [DATE], with diagnoses that included type 2 diabetes mellitus (a disease that occurs when blood glucose/blood sugar is too high.) and heart failure (a condition that develops when the heart doesn't pump enough blood for the body's needs). During a review of Resident 21's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 10/17/2023, the MDS indicated Resident 21 had no speech, rarely/never understood others, and rarely/never made self-understood. Resident 21 was totally dependent (helper does all the effort and resident does none of the effort to complete the activity) for oral hygiene and rolling from left and right. During a concurrent observation and interview on 11/20/2023 at 8:53 am, Resident 21 was lying in bed. Resident 21 had an IV on her left hand secured and covered by transparent dressing. There was no label and date on Resident 21's IV dressing indicating the date the IV was inserted. Registered Nurse Supervisor 2 (RN Sup 2) stated the licensed nurse who inserted the IV should write insertion date and initial. RN Sup 2 stated the IV should be changed every 72 hours for infection control purposes, and if IV site was not dated, licensed nurses would not know when to change it. During a review of the facility's Policy and Procedure titled, I.V. Therapy: Venipuncture (the puncture of a vein with a needle), reviewed 1/13/2023, the P&P indicated, I.V. site should be changed every 72 hours to prevent infection and phlebitis (inflammation of a vein) from occurring. c. During a review of Resident 7's Face Sheet (FS), the FS indicated, Resident 7 was readmitted to the facility on [DATE] with diagnoses that included enterocolitis due to clostridium difficile (inflammation of the colon that results from the disruption of normal healthy bacteria in the colon) and benign prostatic hyperplasia (age-associated prostate gland enlargement that can cause difficulty in urination). During a review of Resident 7's MDS dated [DATE], the MDS indicated Resident 7 had both bladder and bowel incontinence (lack of voluntary control over urination or defecation). During a review of Resident 7's Laboratory Report (LR), dated 11/13/2023, the LR indicated Resident 7 had an elevated BUN result of 70 milligrams per deciliter (mg/dl) with normal reference range of 7-20 mg/dl. During a review of Resident 7's Physician's Orders (PO), dated 11/13/2023, the PO indicated Resident 7 had an order of Half (1/2) Normal Saline (a half-strength normal saline solution indicated for 555649 Page 11 of 21 555649 11/22/2023 West Covina Medical Center D/P Snf 725 S. Orange Avenue West Covina, CA 91790

F 0694 the treatment of dehydration or hypervolemia) at 50 milliliter per hour (ml/hr.) for BUN of 70. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 11/20/2023 at 8:58 am, with the Licensed Vocational Nurse 3 (LVN 3) inside Resident 7's room, Resident 7 had a peripheral intravenous (IV, a soft, flexible tube placed inside a vein) site on the right leg. The IV site was not dated and timed when it was inserted, not initialed by the one who inserted and the IV site dressing was loose. LVN 3 stated the IV site should be labeled with date and time when it was inserted and initialed with the nurse who inserted the IV line to know when to change the IV site to prevent infection. LVN 3 stated the IV site should be change every 72 to 96 hours. Residents Affected - Some During an interview on 11/20/2023 at 2:42 pm, with Registered Nurse Supervisor 1 (RN Sup 1), RN Sup 1 stated IV sites should be dated and timed when it was inserted and initialed with the nurse who inserted it to know when to change the site. RN Sup 1 stated, IV sites should be changed or rotated every 4 days to prevent infection. During an interview on 11/21/2023 at 2:54 pm with the Director of Nursing (DON), the DON stated IV sites should be dated and timed when it was started and initialed by the one who started. The DON stated, IV sites should be assessed visually and physically for signs of infection daily. The DON stated IV sites should be changed every 72 to 96 hours and monitored if IV site was useable. During a review of the facility's P&P titled, I.V Therapy: Venipuncture, reviewed 1/13/2023, the P&P indicated, I.V. site should be changed every 72 hours to prevent infection and phlebitis from occurring. During a review of the facility's P&P titled, Intravenous Infusion, reviewed 3/18/2023, the P&P indicated, The I.V. site shall be selected following criteria of venipuncture procedure. Sterile dressing shall be applied over the I.V. site. IV site to be initialed, dated, and timed. b. During a review of Resident 20's admission record, the admission record indicated, the facility readmitted Resident 20 on 7/7/2022 with diagnoses that included dysphagia (difficulty swallowing), urinary tract infection (UTI, infection in any part the urinary system) and pneumonia (a lung infection). During a review of Resident 20's MDS dated [DATE], the MDS indicated, Resident 20's cognition for daily decision making was severely impaired. The MDS indicated Resident 20 required total dependence with two-person physical assistance with bed mobility, transfer (how resident moves between surfaces including to or from bed, chair, wheelchair, standing position), dressing, eating, toilet use and personal hygiene. During a review of Resident 20's Physicians Order, dated 11/14/2023, the physician's order indicated to start intravenous antibiotics (medication to treat infection) once intravenous access was available. During a review of Resident 20's undated Care Plan titled, IV Therapy Care Plan, the care plan interventions included for nursing staff to rotate peripheral and subcutaneous sites every 96 hours and as needed. During a concurrent observation and interview on 11/20/2023 at 9:40 am with Registered Nurse Supervisor 1 (RN Sup 1), Resident 20 was asleep in bed with IV site not dated when it was inserted. RN Sup 555649 Page 12 of 21 555649 11/22/2023 West Covina Medical Center D/P Snf 725 S. Orange Avenue West Covina, CA 91790

F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1 stated Resident 20's peripheral IV line should be labeled with date when it was inserted and initial of the nurse who inserted the IV line. RN Sup 1 stated IV line should be changed every 4 days to prevent infection. During an interview on 11/20/2023 at 2:46 pm with the Assistant Director of Nursing (ADON), the ADON stated there was no other clinical documentation in Resident 20's clinical record as to when the IV line was inserted. The ADON stated Resident 20's peripheral IV line should be labeled with the date inserted and initial of the licensed staff who inserted the IV line. The ADON stated, IV site should be dated to identify when to change the IV site to prevent infection. During an interview on 11/21/2023 at 3:01 pm with the Director of Nursing (DON), the DON stated Resident 20's peripheral IV line should be labeled with the date, time and initial of the licensed staff who initiated the IV line. The DON stated, IV site should be changed every 72 hours to 96 hours to prevent infection. During a review of the facility's P&P titled, Peripheral IV Catheter Insertion, revised on April 2016, the P&P indicated, IV site should be changed every 72 hours to prevent infection and phlebitis (inflammation of a vein near the surface of the skin). 555649 Page 13 of 21 555649 11/22/2023 West Covina Medical Center D/P Snf 725 S. Orange Avenue West Covina, CA 91790

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on interview and record review, the facility failed to ensure competent nursing staff for two of five staff (Licensed Vocational Nurse 7 [LVN 7], and Registered Nurse Supervisor 3 [RN Sup 3]) by failing to ensure the Department Manager completed and validated the performance evaluation as indicated in the facility's Policy and Procedure titled Evaluation Process. This deficient practice had the potential for residents not to receive appropriate nursing care and services. Findings: During a concurrent record review and interview on 11/20/2023 at 2:04 pm with the Director of Staff and Development (DSD), LVN 7's employee file was reviewed. The DSD stated LVN 7 worked full time in the facility since 4/22/2021. During a concurrent record review and interview on 11/20/2023 at 2:10 pm with the DSD, RN Sup 3's employee file was reviewed. The DSD stated RN Sup 3 worked full time in the facility since 4/9/2015. During a concurrent record review of the licensed staff's Performance Evaluation and interview on 11/20/2023 at 3:28 pm with the DSD, the DSD stated the Assistant Director of Nursing (ADON) was responsible to complete and validate the performance evaluation for all the licensed staff every year. The DSD stated, it was the ADON who completed and validated the performance evaluation for LVN 7 and RN Sup 3. During a concurrent record review and interview on 11/20/2023 at 4:10 pm with the Human Resource Coordinator (HRC), the HRC stated, she did not know who signed and completed the performance evaluation for LVN 7 and RN Sup 3. HRC stated the person who can access the employee file was the HRC and Nursing Administrator Assistant (NAA). During a concurrent record review and interview on 11/20/2023 at 4:10 pm with the NAA, the NAA stated, she did not know who completed the Performance Evaluation for LVN 7 and RN Sup 3. During a concurrent record review and interview on 11/20/2023 at 3:36 pm with the ADON, the ADON stated she did not complete the performance evaluation for LVN 7 and RN Sup 3. ADON stated These were not my penmanship and signatures; I did not do this. ADON stated, NAA needed to give the ADON the performance evaluation form to complete and discuss in person together with the licensed staff with the result of their performance evaluation. During an interview on 11/21/2023 at 8:48 am with the DON, the DON stated, the ADON needed to complete and validate the performance evaluation for the licensed staff to determine staff were competent to provide the care, treatment, and services the residents needed. During a review of the facility's Policy and Procedure (P&P) titled, Evaluation Process, reviewed 2/17/2022, the P&P indicated at the end of each month, the Human Resource department will notify the Department Manager of evaluations due for the following month. The Manager or Supervisor is to notify the employee of the evaluation at least (yearly) prior to employee's evaluation due date and give them any applicable forms. P&P indicated factors that will be considered in making decisions . are 555649 Page 14 of 21 555649 11/22/2023 West Covina Medical Center D/P Snf 725 S. Orange Avenue West Covina, CA 91790

F 0726 not limited to job performance, achieving preset goals, attendance to work, adherence to workplace policies, etc. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 555649 Page 15 of 21 555649 11/22/2023 West Covina Medical Center D/P Snf 725 S. Orange Avenue West Covina, CA 91790

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 obtain a consent for psychotropic medication (any drug that affects behavior, mood, thoughts, or perception) use for two of five sampled residents (Residents 1 and 18). This failure had the potential for Resident 1 and 18 to receive unnecessary medications. Findings: a. During a review of Resident 18's Face Sheet, the face sheet indicated Resident 18 was admitted on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD- type of obstructive lung disease characterized by long-term poor airflow) and hypertension (increased blood pressure). During a review of Resident 18's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 8/10/2023, the MDS indicated Resident 18 had unclear speech, sometimes understood others, and sometimes made self-understood. Resident 18 was totally dependent (full staff performance) for bed mobility, dressing and personal hygiene. During a review of Resident 18's Physician Order dated 9/7/2023, the physician's order indicated for Resident 18 to receive Buspar (Buspirone, a medication that treats anxiety) 5 milligrams (mg) twice a day. During a concurrent interview and record review of Resident 18's clinical record on 11/21/2023 at 9:13 am, the Director of Nursing (DON) stated the facility did not obtain a consent before Buspar was administered to Resident 18. The DON stated there was no consent when the physician increased Buspar from 5mg to 7.5 mg on11/14/2023. The DON stated the facility needed to obtain a consent for all psychotropic drugs from residents or their family members to explain the benefits and risks of taking the medication. The DON stated it was Resident 18's right to provide consent and to prevent unnecessary medication given to Resident 18. During a review of the facility's Policy and Procedure (P&P) titled, Psychotherapeutic Agents and restraints Review Process reviewed 1/13/2023, the P&P indicated, The patient/SO (significant others) will complete the Voluntary Consent Form for physical restraints and/or Psychotropic Drug Therapy. The consent will include the drug and the amount ordered. A new consent will be obtained each time the drug is increased. b. During a review of Resident 1's admission record, the admission record indicated the facility admitted Resident 1 on 4/22/2022 with diagnoses that included elevated white blood cell count (WBC - part of body's immune system that helps to fight infection), 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 1's Physician order, dated 6/15/2022, the physician's order indicated to give Resident 1 Lorazepam (antianxiety [medication to treat anxiety [emotion characterized by 555649 Page 16 of 21 555649 11/22/2023 West Covina Medical Center D/P Snf 725 S. Orange Avenue West Covina, CA 91790

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some feelings of tension, worried thoughts and physical changes]), one (1) milligrams (mg), 1 tablet via gastrostomy tube (GT- a tube inserted through the abdomen that delivers nutrition/medication directly to the stomach) every two hours, as needed for jerking (not for psychotropic [any medication capable of affecting the mind, emotions, and behavior] use). During a review of Resident 1's MDS dated [DATE], the MDS indicated, Resident 1's cognition for daily decision making was severely impaired. The MDS indicated Resident 1 required total dependence with two-person physical assistance with bed mobility, transfer (how resident moves between surfaces including to or from bed, chair, wheelchair, standing position), dressing, and toilet use. During a concurrent record review and interview on 11/20/2023 at 4:04 pm with the Assistant Director of Nursing (ADON), the ADON stated Facility Verification of Informed Consent was not obtained from Resident 1 or Resident's 1 responsible party for the use of Lorazepam. The ADON stated it was important to have an informed consent for residents receiving psychotropic medications because they have the right to be involved in the care and had the potential to cause adverse (harmful) effect to the residents. During a record review of the facility's P&P titled, Psychotherapeutic Agents and Restraints Review Process, dated 1/13/2023, the P&P indicated the patient/SO will complete the voluntary consent form for physical restraints and/or psychotropic drug therapy. The consent will include the drug and the amount ordered. P&P indicated the physician will sign the informed consent verification for psychotropic drugs and/or restraints and a specific informed consent for antipsychotic medications. 555649 Page 17 of 21 555649 11/22/2023 West Covina Medical Center D/P Snf 725 S. Orange Avenue West Covina, CA 91790

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** c. During a review of Resident 21's Face Sheet, the face sheet indicated Resident 21 was admitted on [DATE], with diagnoses that included type 2 diabetes mellitus (a disease that occurs when blood glucose/blood sugar is too high) and heart failure (a condition that develops when heart doesn't pump enough blood for the body's needs). Residents Affected - Some During a review of Resident 21's MDS dated [DATE], the MDS indicated Resident 21 had no speech, rarely/never understood others, and rarely/never made self-understood. Resident 21 was totally dependent (helper does all the effort; resident does none of the effort to complete the activity) for oral hygiene and rolling from left and right. During a concurrent observation and interview with Registered Nurse Supervisor 2 (RN Sup 2) on 11/20/2023 at 8:53 am, Resident 21 was lying in bed. Resident 21 had a tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs) with a T-Bar (a T shaped device) and oxygen tubing to provide Resident 21 oxygen. Resident 21's oxygen tube was not labeled. RN Sup 2 stated, there was no label or date on Resident 21's oxygen tubing. During an interview on 11/20/2023 at 2:43 pm, Respiratory Care Therapist 2 (RT 2) stated it was the facility's policy that oxygen tubing needed to be changed every 7 days or as needed when soiled. RT 2 stated respiratory care therapists were in charge of oxygen tubing change. RT 2 stated RTs changed oxygen tubing on specific days based on a changing schedule and should label the tubing with the date it was changed. RT 2 stated labeling the oxygen tube was to prevent infection because microorganism may grow from long time use of the oxygen tubing. During a review of the facility's undated Respiratory Equipment Change Schedule, the schedule indicated, All disposable equipment is single patient use only. All equipment must be properly labeled (date, patient initials, room number). During a review of the facility's Policy and Procedure (P&P) titled, Oxygen Cannula, reviewed 4/13/2023, the P&P indicated, Oxygen tubing/cannulas are to be dated weekly and as needed. 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) for three of three sampled residents (Residents 1, 20 and 21) by failing to ensure: a. Registered Nurse Supervisor 2 (RN Sup 2) performed hand hygiene before contact with Resident 1. b. Licensed Vocational Nurse 2 (LVN 2) performed hand hygiene before contact with Resident 20. c. Resident 21's nasal cannula ( tube which on one end splits into two prongs which are placed in the nostrils to deliver oxygen) tubing was labeled and dated. These deficient practices placed the residents at risk for infection. Findings: 555649 Page 18 of 21 555649 11/22/2023 West Covina Medical Center D/P Snf 725 S. Orange Avenue West Covina, CA 91790

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some a. During a review of Resident 1's admission record, the admission record indicated the facility admitted Resident 1 on 4/22/2022 with diagnoses that included elevated white blood cell count (WBC - part of body's immune system helps to fight infection), 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 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 4/26/2023, the MDS indicated, Resident 1's cognition (ability to understand) for daily decision making was severely impaired. The MDS indicated Resident 1 required total dependence with two-person physical assistance with bed mobility, transfer (how resident moves between surfaces including to or from bed, chair, wheelchair, standing position), dressing, and toilet use. During a concurrent observation and interview on 11/20/2023 at 8:41 am with RN Sup 2, Resident 1 was asleep in bed. RN Sup 2 was providing care to Resident 1's roommate. RN Sup 2 did not change gloves and did not perform hand hygiene before touching Resident 1. RN Sup 2 stated, he did not change his gloves and did not perform hand hygiene before touching Resident 1. RN Sup 2 stated he needed to change gloves and perform hand washing between resident contact to prevent the spread of infection and cross contamination (the process by which bacteria or other microorganisms are transferred from one substance or object to another). b. During a review of Resident 20's admission record, the admission record indicated the facility readmitted Resident 20 on 7/7/2022 with diagnoses that included dysphagia (difficulty swallowing), urinary tract infection (UTI, condition in which bacteria invade and grow in any part the urinary system) and pneumonia (a lung infection). During a review of Resident 20's MDS dated [DATE], the MDS indicated Resident 20's cognition for daily decision making was severely impaired. The MDS indicated Resident 20 required total dependence with two-person physical assistance with bed mobility, transfer, dressing, eating, toilet use and personal hygiene. During a review of Resident 20's Care Plan titled, Risk for infections, dated 10/2/2023, the care plan interventions included for nursing staff to practice good infection control. During a review of Resident 20's Physicians Order, dated 11/14/2023, the physician's order indicated to administer Invanz (antibiotic that is used to treat severe infections caused by bacteria) 1 gram (g) daily via intravenous piggyback (also known as IVPB - method of administering medication through an intravenous line) for 7 days for Proteus Mirabilis (bacteria) of the sputum (matter expectorated from the lungs). During a concurrent observation and interview on 11/20/2023 at 9:02 am with LVN 2, Resident 20 was asleep in bed. LVN 2 was performing care to Resident 20's roommate. LVN 2 did not change gloves and did not do hand hygiene before touching Resident 20's gastrostomy tube (GT- a tube inserted through the abdomen that delivers nutrition directly to the stomach). LVN 2 stated, she needed to change gloves and perform hand hygiene before touching Resident 20. LVN 2 stated she needed to change gloves and perform hand washing between resident contacts to prevent the spread of infection. During an interview on 11/20/2023 at 10:23 am with the Assistant Director of Nursing (ADON), the ADON stated staff should change gloves and perform hand hygiene between resident contacts to prevent the spread of infection. 555649 Page 19 of 21 555649 11/22/2023 West Covina Medical Center D/P Snf 725 S. Orange Avenue West Covina, CA 91790

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 11/21/2023 at 3:03 pm with the Director of Nursing (DON), the DON stated staff should perform hand hygiene before and after Resident 20's care to prevent contamination and spread of infection. During a record review of the facility's Policy and Procedure (P&P titled), Infection Prevention and Control Program, dated 4/2023, the P&P indicated all staff shall wash their hands between resident contacts. 555649 Page 20 of 21 555649 11/22/2023 West Covina Medical Center D/P Snf 725 S. Orange Avenue West Covina, CA 91790

F 0908 Keep all essential equipment working safely. 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 maintain patient care equipment in safe operating condition for one of two beds inspected and the facility staff did not communicate with the facility Maintenance Department when the bed indicators flashed. Residents Affected - Few This failure had the potential to result in compromised resident's safety. Findings: During an observation of the facility on 11/20/2023 at 8:48 am, while in Resident 6's room, Resident 6 was lying in a bed with multiple LED (light-emitting diode) indicators flashing that included [NAME] 30+(patient's head is elevated more than 30 degrees), low height, bed exit and side rails. During an observation on 11/20/2023 at 3:37 pm, in Resident 6's room, Resident 6's bed had the LED flashing with the same indicators observed from this morning at 8:48 am. During an observation on 11/21/2023 at 9:38 am, in Resident 6's room, Resident 6's bed had the LED flashing with the same indicators observed from yesterday (11/20/2023). During a concurrent observation and interview on 11/21/2023 at 9:42 am, in Resident 6's room, Certified Nursing Assistant 2 (CNA 2) stated she did not pay attention to Resident 6's bed with flashing indicators. CNA 2 stated, flashing bed indicators indicated something was wrong with the bed and needed to be fixed. CNA 2 stated she needed to be more alert with patient care equipment, report to the charge nurse if the bed had flashing indicators and have Maintenance Department check the bed to ensure the equipment was in good working condition for patient's safety. During an interview on 11/21/2023 at 9:50 am, Plant Operation Manager (POM) stated, when the bed alarms/indicators flashed, it indicated the bed had problems/issues. The POM stated the nurses needed to communicate with the Maintenance Department for any problem of patient care equipment including flashing LED alarms in beds. During a review of the facility's Policy and Procedure titled, Maintenance Inspection/Communication, reviewed 4/5/2023, the P&P indicated, Staff shall communicate with the Maintenance Department and identify any broken or malfunctioning equipment in the maintenance log. All maintenance concerns shall be identified in the maintenance log. 555649 Page 21 of 21