Health inspection·July 9, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility failed to promote respect and dignity for one of two sampled residents (Resident 109) by failing to ensure, Resident 109's urinary catheter (a thin tube that goes in through the urethra [part of resident's anatomy of the urinary tract that connects the bladder with the outside of the body]) drainage bag was covered with a privacy bag. This failure had the potential to affect Resident's 109's psychosocial (mental, emotional, social interactions) wellbeing. Findings: A review of Resident 109's Face Sheet (an admission Record) indicated Resident 109 was admitted to the facility on [DATE] with diagnoses that included benign prostatic hyperplasia (BPH-a noncancerous enlargement of the prostate gland [a firm muscular gland situated at the base of the male urethra]) diabetes mellitus (a condition that affects the way the body processes blood sugar and result in high blood sugar). A review of Resident 109's TCU (Transitional Care Unit) baseline care plan, dated 6/30/23, indicated Resident 109's cognitive (process of acquiring knowledge and understanding through thought, experience, and the senses) status was alert and oriented. The plan of care did not indicate how the resident will be provided privacy and dignity while having urinary catheter. During an observation on 7/7/23 at 10:19 AM, Resident 109's urinary catheter drainage bag was uncovered with a privacy bag (opaque bag put over a drainage bag to prevent someone from seeing the drainage). In a concurrent interview Resident 109 stated I have been here for over a week and there has not been a cover on my catheter. During an observation on 7/7/23 at 11:15 AM, while inside Resident 109's room with Registered Nurse (RN 2), Resident 109's urinary catheter was not covered with a privacy bag. In a concurrent interview, RN 2 stated Resident 109's urinary catheter should had been covered with a privacy bag, and she had not noticed the urinary bag was not covered. During an interview on 7/7/23 at 11:45 AM with Clinical Manager (CM 1), CM 1 stated when a Resident is admitted with a urinary catheter, the admitting nurse should cover the urinary catheter drainage bag according to the facility's standards of practice. During an interview on 7/9/23 at 4:47 PM, CD 1 stated the facility does not have a policy and Page 1 of 16 555654 555654 07/09/2023 Presbyterian Intercomm Hosp Dp/Snf 12401 Washington Blvd. Whittier, CA 90602

F 0550 Level of Harm - Minimal harm or potential for actual harm procedure to ensure the residents were provided respect and dignity, such a providing a dignity bag for all residents with a urinary catheter. CD 1 stated it is a facility practice for the nurses to place privacy bag to cover all resident's urinary catheter drainage bag with a privacy bag to provide respect and dignity to each resident. Residents Affected - Few 555654 Page 2 of 16 555654 07/09/2023 Presbyterian Intercomm Hosp Dp/Snf 12401 Washington Blvd. Whittier, CA 90602

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide a written and verbal notification about Bed Hold (is when a nursing home holds a bed for you when you go into the hospital) to the resident and the resident's legal representative for one of two sampled resident's (Resident 7) who was transferred to the General Acute Care Hospital (GACH) due to a change in condition that required a higher level of care. This failure resulted in violation of the resident's rights to ensure the resident's and the legal representative could make informed decisions about the duration of Bed Hold and the resident's rights to return to the facility from the GACH. Findings: A review of Resident 7's Face Sheet (an admission Record) indicated Resident 7 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus type 2 (a condition that affects the way the body processes blood sugar and result in high blood sugar), peripheral neuropathy ( a nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness in different parts of the body, and hypertension (a condition in which the force of the blood against the artery walls is too high causing high blood pressure). A review of Resident 7's Minimum Data Set (MDS, a standardized care screening and assessment tool), dated 4/11/23 indicated, Resident 7 was cognitively (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) intact. A review of Resident 7's Physician Order, dated 4/12/2023 at 3:42 P.M. indicated to discharge Resident 7 to the GACH on 4/12/23. A review of Resident 7's TCU (Transitional Care Unit) discharge summary record, dated 4/13/2023 at 8:26 AM, indicated Resident 7 was discharged on 4/12/2023 to the GACH. During an interview on 7/09/23 at 3:26 PM, the Clinical Director (CD) stated, the facility did not provide Resident 7 or Resident 7's family or legal representative a written notification about Bed Hold when Resident 7 was transferred to the GACH, because Resident 7 was transferred with a Covid 19 (A highly contagious respiratory disease) diagnosis. In a concurrent interview the CD stated the facilities Covid 19 Mitigation Plan (acts as a step-by-step guide for facility to prevent spread of COVID 19) for April (revision date of April 03, 2023) indicated, if the resident was transferred to the GACH with a COVID 19 diagnosis, During an interview and concurrent record review with Infection Preventionist Nurse (IP 1) on 7/09/23 at 3:51 PM, IP stated the facility's Mitigation Plan did not have a documented evidence that indicated the facility was exempted from providing the resident and his/her representative about Bed Hold notification when transferred to GACH due to COVID 19 infection. During an interview on 7/9/23 at 3:45 PM the CD stated facility did not have a policy and procedure regarding Bed Hold, but followed the Bed Hold notification section included in facility's admission agreement for skilled nursing facilities. 555654 Page 3 of 16 555654 07/09/2023 Presbyterian Intercomm Hosp Dp/Snf 12401 Washington Blvd. Whittier, CA 90602

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the facility's TCU admission Agreement for skilled nursing facilities and intermediate care facilities, revised on 9/21/22, indicated for Bed holds and readmissions, if residents were transferred to an acute hospital for seven days or less, the facility will notify the resident or their representative that the facility was willing to hold the bed. The resident and their representatives. The admission record indicated the resident or representative have 24 hours after receiving the notice to let the facility know whether he/she wants that facility to hold the bed of the resident. 555654 Page 4 of 16 555654 07/09/2023 Presbyterian Intercomm Hosp Dp/Snf 12401 Washington Blvd. Whittier, CA 90602

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed develop a comprehensive, resident specific plan of care for two of three sampled residents (Resident 117 and Resident 161) as indicated in the facility's policy and procedure. 1. For Resident 117 failure to develop an individualized plan of care with measurable goals, specific interventions and assessment that identifies who and when the interventions are to be implemented for the resident who was receiving hemodialysis (a medical procedure that removes the excess fluid and toxins in the blood with a specialized medical equipment). 2. For Resident 161 the facility did not develop a plan of care for the use of postural support. Findings: 1. A review of Resident 117's Face Sheet (an admission record) indicated the resident was admitted to the facility on [DATE], with diagnoses that included, End Stage Renal Disease (ESRD-kidneys are no longer able to work at a level needed for day-to -day life), and systolic congestive heart failure (failure of the heart to meet the body's demand due to a weak heart). A review of Resident 117's Minimum Data Set (MDS), a standardized assessment and care screening tool) dated 7/03/2023 indicated Resident 117's cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. A review of Resident 117's Physician Orders, dated 6/26/2023, indicated Resident 117 receives Hemodialysis. The physician's order did not indicate the day and time of when the hemodialysis will be done. A review of Resident 117's plan of care dated 6/26/2023, indicated Resident 117 was scheduled for dialysis on Monday, Wednesday, and Fridays with LUA (left upper arm) shunt (aids the connection from a hemodialysis access point to a major artery). During a record review on 7/9/2023 at 12:10 PM, the plan of care did not indicate Resident 117 was receiving dialysis. The plan of care did not indicate the goal, the interventions to be implemented, such as assessment, who and when the plan of care will be implemented, and if the plan of care was evaluated to determine if the plan of care was effective to achieve the goal for the resident to achieve the highest potential or wellbeing. In a concurrent interview the Clinical Director (CD 1) stated, We do not have a specifics on the adult plan of care, if the resident is receiving dialysis, it would state it in the adult plan of care. It does not include assessments or interventions. 2. A review of Resident 161's Face Sheet indicated the resident was admitted to the facility on [DATE] with a diagnosis of acute coccyx fracture (broken tail bone). A review of Resident 161's History and Physical Interval Note, dated 7/4/2023, indicated resident also had diagnoses that included dementia (the loss of cognitive functioning (thinking, remembering, reasoning) to an extent that it interferes with a person's daily life and activities) with Parkinson's Disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, 555654 Page 5 of 16 555654 07/09/2023 Presbyterian Intercomm Hosp Dp/Snf 12401 Washington Blvd. Whittier, CA 90602

F 0656 stiffness, and difficulty with balance and coordination). Level of Harm - Minimal harm or potential for actual harm A review of Resident 161's Minimum Data Set (MDS, an assessment and screen tool) dated 7/8/2023 indicated Resident 161 had severely impaired cognition, that required extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility and transfer. Residents Affected - Few A review of Resident 161's adult plan of care, dated 7/3/2023, indicated the resident was at high fall risk. Plan of care did not indicate interventions in place for fall prevention that were specific to Resident 161. During a concurrent interview and record review of Resident 161's Adult Plan of Care on 7/7/2023, the CD stated the use of the torso/postural support was a standard procedure. Confirmed with the CD and Accrediting & Licensing (AL) staff there was nothing in the adult plan of care that indicated use of torso/postural support. AL staff printed out a copy of Adult Plan of Care. Per CD, the care plan only indicated pending therapy evaluation. A review of the facility's policy and procedure titled Patient plan of Care, revised on 4/1/2023, indicated Each patient will have an individualized plan of care based on needs identified by patient's assessment, reassessment, and results of diagnostic testing. The policy indicated the patient assessment will take in account, patients treatment goals, and as appropriate physiological , psychological factors . The policy also indicated the plan of care is based on patient's goals and time frames, settings, and services required to meet those goals. Based on goals established in patients plan of care, the staff will evaluate the patients' progress. 555654 Page 6 of 16 555654 07/09/2023 Presbyterian Intercomm Hosp Dp/Snf 12401 Washington Blvd. Whittier, CA 90602

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review, the facility failed to provide care related to IV sites/therapy (Intravenous is a small plastic catheter placed through the skin into the vein used to give fluids and medications) based on to the professional standard of practice and the facility's policy and procedure for two of two sampled residents (Resident 63 and Resident 66). Residents Affected - Some 1. Resident 63's, IV medication bag was not labeled with the date and time the antibiotic (medication used to treat infection) was administered. Resident 63's IV tubing was not labeled with the date and the tubing was first used. 2. Resident 66's IV site dressing/tape (plastic tape or gauze covering the IV) on the left arm was not labeled with date and time of when the IV site was dressing/tape was change. Resident 66's IV site had not physician order on how to monitor and care for the IV site to prevent infection.e. Resident 66's IV was discontinued by the facility staff without the physician's order. This deficient practice had the potential to increase complications associated with intravenous therapy such as infection. Findings: 1. A review of Resident 63's face sheet (an admission record) indicated the resident was admitted to the facility on [DATE], with a diagnosis of septic arthritis (a painful infection in a joint that can come from germs that travel through the bloodstream from another part of the body). A review of Resident's 63's Patient Transfer Orders (a physician order), dated 7/3/2023, indicated to administer Ceftriaxone (a medication used to treat infection) via IV piggyback (IVPB, medication administered via secondary IV tubing connected to the primary tubing), 2 grams (g-a unit of measure) in 50 milliliters (ml, unit of measure) dextrose (fluid with sugar) to infuse over 30 minutes every 24 hours for septic arthritis. During an observation on 7/7/2023 at 10:49 AM, Resident 63 was observed with an empty antibiotic IV bag hanging on an IV pole at bedside. The IV bag had no label that indicate the date and time of when IV bag was opened and administered. During an interview with Registered Nurse (RN) 2 on 7/7/2023 at 11:23 AM, RN 2 stated Resident 63's IV tubing should be labeled with the date and time to know when it was started. RN 2 stated the IV antibiotic bag should have the date, and time when medication was given. 2. A review of Resident 66's Face Sheet indicated the resident was admitted to the facility on [DATE], with a diagnosis of spondylosis lumbar (degeneration of lumbar vertebrae, a form of low back pain)/posterior spinal diskectomy fusion (surgical procedure used to correct problems with the small bones in the spine) lumbar three to lumbar (lower region of the spine) five. A review of Resident 66's History and Physical Interval Note, dated 7/5/2023, indicated the resident was admitted to the facility for further physical therapy (care that relieve pain and help one 555654 Page 7 of 16 555654 07/09/2023 Presbyterian Intercomm Hosp Dp/Snf 12401 Washington Blvd. Whittier, CA 90602

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some move better or strengthen weakened muscles) and medical management. The History and Physical indicated Resident 66 was alert and oriented to person, place, and time. During an observation on 7/7/2023 at 11:50 AM, Resident 66's IV dressing on the left hand was peeling off and without a label that indicated the date and time the IV dressing was last changed. In a concurrent interview, Resident 66 stated he could not recall when the IV dressing was last changed. Resident 66 stated the IV on his left arm was inserted at the hospital but could not recall when the peripheral IV was inserted at the hospital. During an interview on 7/7/2023 at 11:53 AM, RN 3 stated the resident's IV dressing should be labeled with the date and time of when the dressing was changed, and when the IV was inserted. During an interview and concurrent record review of Resident 66's Patient Transfer Orders, with the Clinical Manager (CM) on 7/7/2023 at 5:05 PM, the CM stated, Resident 66's IV was discontinued today. The CM confirmed and stated there was no physician orders on how to maintain and care for the Resident 66's IV, and there was no order to discontinue the IV today. The CM stated it was a part of the facility standard of practice to have a physician's order to maintain, care and discontinue the IV sites. A review of the facility's policy and procedure titled Intravenous Therapy for Adults and Pediatrics Peripheral and Central, revised 7/13/2022 indicated labeling of IV tubing, IV site and IV bags are required when the resident is admitted . The policy indicated all IV sites will be changed only as clinically warranted based on integrity and patency of the site and labeled with initiation date and time. The policy indicated a physician will write orders for the following: insertion or discontinuation of a peripheral IV. 555654 Page 8 of 16 555654 07/09/2023 Presbyterian Intercomm Hosp Dp/Snf 12401 Washington Blvd. Whittier, CA 90602

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed ensure one of one sampled resident (Resident 161) who was at high risk for fall and accident due to impaired cognition (thought process and ability to reason), unsteady gate and restlessness was provided safety to prevent injuries by failing to: 1. ensure Resident 161 was assessed by the licensed staff and the physician prior to the use of Posey torso support belt (five-inch-wide belt with shoulder straps for wheelchairs or similar non-wheelchair applications) for the risk for accident and entrapment (the state of being caught in or as in a trap.). 2. a plan of care was developed with interventions that indicated how and who will assess and monitor Resident 161 while using the Posey torso support belt. 3. a plan of care was developed to indicate interventions on how the resident will be provided safety and hazard free accident to prevent falls, accidents, and injuries. This deficient practice had the potential for Resident 161 to sustain serious injuries and entrapment that could result in the decline in the resident's wellbeing. Findings: A review of Resident 161's face sheet (admission records) indicated the resident was admitted to the facility on [DATE], with a diagnosis of acute coccyx fracture (broken tail bone). A review of Resident 161's History and Physical Interval Note, dated 7/4/2023, indicated the resident also had diagnoses that included dementia (the loss of cognitive functioning [thinking, remembering, reasoning] that interferes with daily life and activities) and Parkinson's disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). A review of Resident 161's Adult Plan of Care, dated 7/3/2023, indicated the resident was at high risk for fall. The Plan of care did not indicate the risk factors for falls and the interventions to prevent Resident 161 from fall and/or accident, including when the Posey torso support was in use. A review of Resident 161's Minimum Data Set (MDS, an assessment and screen tool), dated 7/8/2023, indicated Resident 161 had severely impaired cognition and required extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility and transfer. A review of Resident's 161's Patient Transfer Orders indicated, a physician ordered on 7/3/2023, did not include to use Posey torso support. During an observation on 7/7/2023 at 10:26 AM, Resident 161 was observed sitting up in wheelchair wearing a Posey torso support. During an observation on 7/7/2023 at 3:55 PM, Resident 161 was observed sitting up in wheelchair wearing a Posey torso support with Family member (Family 1) present. Family 1 stated Resident 161 555654 Page 9 of 16 555654 07/09/2023 Presbyterian Intercomm Hosp Dp/Snf 12401 Washington Blvd. Whittier, CA 90602

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wears the Posey torso support to prevent the resident from falling out of the wheelchair because Resident 161 could get restless. During an observation on 7/7/23 at 4:17 PM, Resident 161 was observed still wearing the Posey torso support belt with Velcro (define) straps parallel from her shoulders down the front. Family 1 stated Resident 161 had a difficult time getting out of the Posey torso support belt without assistance. Family 1 stated Resident 161 has tried to get out, but she was not successful. During a concurrent interview and record review of Resident 161's physician orders with Registered Nurse (RN) 4 on 7/7/2023 at 4:20 PM, RN 4 stated Resident 161 had Posey torso belt support to keep the resident upright whenever she's in a wheelchair. RN 4 stated if the straps are parallel to shoulders down her front, it is not a restraint (any manual method, physical or mechanical device/equipment or material that limits a resident's freedom of movement and cannot be removed by the resident in the same manner as it was applied by staff). RN 4 confirmed there was no documentation that the physician ordered Resident 161 to use the Posey torso support. RN 4 also confirmed Resident 161 was not assessed for risk of accident or entrapment by the physician or the licensed staff assessed that Resident 161 could be safely use Posey torso support belt. During an interview with the Clinical Director (CD) on 7/7/2023 at 4:32 PM, the CD explained, the facility does not need a physician's order for the use Posey torso/postural support belt. The CD stated the use of Posey torso/postural support belt was determined based on the nursing assessment of the resident who was at high fall risk or needs postural support. The CD stated the Posey torso/postural support belt was not classified as a restraint. During an interview on 7/7/23 at 6:16 PM, the CD stated, the use of the torso/postural support belt in the facility was a standard procedure (standard and commonly practiced) in the facility. During an interview with licensed vocational nurse (LVN) 1 on 7/8/2023 at 3:37 PM, LVN 1 stated Resident 161 was restless, and the torso/postural support belt was for the safety of the resident to prevent falls. LVN stated the use of the torso/postural support belt was standard procedure and there was no actual assessment or documentation or monitoring of the residents to identify why the resident need the Posey. A review of the facility's policy and procedure titled Fall Prevention and Management in Adults, dated 7/3/2023 indicated after resident has been assessed for fall risk, appropriate interventions will be implemented based on risk level. The policy indicated any resident will be assessed/reassessed for risk of fall and shall have a basic set of interventions deployed to prevent a fall. A review of the manufacturer's guideline for the use of Posey torso support belt indicated, the product applications was considered self-release or assisted release which must be specified by the ordering physician. The manufacturer's guideline indicated the product is designed for self-release. The manufacturer's guideline indicated if the resident is not able to easily self-release, it is considered a restraint and must be prescribed by a physician. 555654 Page 10 of 16 555654 07/09/2023 Presbyterian Intercomm Hosp Dp/Snf 12401 Washington Blvd. Whittier, CA 90602

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the facility's Transitional Care Unit Dialysis (is a life-support treatment that uses a special machine to filter harmful waste, salt, and excess fluid from your blood) Communication Record were completed on 6/28/2023 and 7/7/2023 for one of two sampled resident (Resident 117) who was receiving hemodialysis treatments. Residents Affected - Few This deficient practice had the potential for the resident to have delayed or fail to receive necessary interventions when they experience complications related to dialysis such as bleeding on the dialysis access site (formed by the joining of a vein and an artery in an area in the body that connects to the dialysis machine), low blood pressure and low heart rate or severe weakness. Findings: A review of Resident 117's Face Sheet (an admission Record) indicated the resident was admitted to the facility on [DATE], with diagnoses that included End Stage Renal Disease (ESRD- when the kidneys are no longer able to work at a level needed for day-to -day life), and systolic congestive heart failure (failure of the heart to meet the body's demand due to weak heart). A review of Resident 117's Minimum Data Set (MDS), a standardized assessment and care screening tool), dated 7/03/2023, indicated Resident 117's cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. A review of Resident 117's Physician Orders, dated 6/26/2023, indicated Resident 117 receives Hemodialysis. The physician's order did not indicate the day and time of when the hemodialysis will be done. During a concurrent interview and record review of Resident 117's Transitional Care Unit Dialysis Communication Record form on 7/9/23 at 11:28 AM, the Infection Prevention Nurse (IP 1) stated, the licensed nurses did not complete the Pre Access site Assessment Dialysis Assessments form on 6/28/23 and Pre and Post Dialysis Access site assessment form on 7/07/2023. During a concurrent interview and record review on 7/09/23 at 12:10 PM, the Clinical Director (CD 1) stated, it was important for the nurses to assess the resident's hemodialysis access site before and after hemodialysis and document the assessments to identify any change of condition of the resident to make sure there was no bleeding on the access site and the access site was still working after the hemodialysis. The CD 1 explained, the facility does not have a policy to address the procedures or guidelines to care for residents receiving hemodialysis that address the assessments to be conducted before and after hemodialysis and what complications to monitor and assess according to the current standard of nursing practice. 555654 Page 11 of 16 555654 07/09/2023 Presbyterian Intercomm Hosp Dp/Snf 12401 Washington Blvd. Whittier, CA 90602

F 0838 Level of Harm - Minimal harm or potential for actual harm Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on interview and record review the facility did not conduct, document, and review a Residents Affected - Some Annual Facility Assessment (a facility wide assessment of the facility that included plan that define the process of strategizing, or directing, and making decisions on allocating its resources to enable each nursing home to thoroughly assess the needs of their resident population and the required resources needed to provide the care and services that residents need) as described in the regulations for long term care facilities for 23 of 23 residents in the census. This deficient practice had the potential for the residents in the facility not to receive the care and services needed to achieve their highest potential. Findings: During an initial conference on 7/7/23 at 8:45 AM, the Clinical Director (CD1) and the [NAME] President of Regulatory Affairs (VP 1) was presented with an initial conference worksheet from the CMS (Centers for Medicare and Medicaid Services) indicating the required documents for the re-certification process. A review of the initial conference worksheet included the Facility Assessment, which should be provided to the surveyors within four hours after the entrance conference with the facility Administrator or designee. A review of the documents received from the facility on 7/7/23 at 3:30 PM, did not include the Annual Facility Assessment. During an interview on 7/8/23 at 10:30 A.M., the CD 1 stated, the facility was exempt from providing Annual Facility Assessment because the facility was directly connected to GACH (General Acute Care Hospital), therefore the Distinct Part or the Skilled Nursing part of the facility were covered under GACH assessment. The CD 1 stated the facility did not perform a facility wide assessment as required by the CMS for the Long-Term Care facilities, and have no policy and procedure regarding Annual Facility Assessment During an interview on 7/9/23 at 6:00 PM with the VP stated, the facility did not complete a facility wide assessment. The VP stated, the facility had no documentation that indicated the facility was exempt from the CMS compliance related to development of Annual Facility Assessment. 555654 Page 12 of 16 555654 07/09/2023 Presbyterian Intercomm Hosp Dp/Snf 12401 Washington Blvd. Whittier, CA 90602

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 maintain and prevent the spread and transmission of herpes zoster (known as shingles is the same virus that causes chickenpox which can spread from spread from person to person though contact) infection for one of one sampled resident (Resident 59). Residents Affected - Few Resident 59's family (FAM2) was observed in nursing station wearing an isolation gown (gown used to protect clothing from contaminants or contacting disease causing organism), facemask and gloves that was used while visiting Resident 59. FAM 2 was observed returning to Resident 59's room wearing the same gown. This deficient practice had the potential to spread the infection to the residents, staffs, and other visitors in the facility. Findings: A review of Resident 59's face sheet (admission records) indicated the resident was admitted to the facility on [DATE], with diagnosis of status post (after) left hip open reduction with internal fixation (ORIF, procedure performed to repair a complex or severe hip fracture.) A review of Resident's 59's Patient Transfer Orders (a physician's order), dated 6/29/2023, indicated to administer Valacyclovir (a medication used to treat infection) 1000 milligram (mg, unit of measure) by mouth, every 12 hours for seven days for herpes zoster. During an observation on 7/7/2023 at 11:55 AM, a contact isolation (containing one in an area prevent transmission of infectious agents which are spread by direct or indirect contact with the residents or the resident's environment) signage was observed prior to entering Resident 59's room. The signage indicated proper use of PPE (Personal Protective Equipment) that included: surgical mask, isolation gown and gloves to use prior to entering the room. During an observation on 7/7/2023 at 12:40 PM, FAM 2 was observed leaving the nursing station and returning to Resident 59's room, wearing PPE, a surgical mask, isolation gown and gloves. During an interview on 7/7/2023 at 12:43 PM, FAM 2 stated he walked into Resident 59's room without PPE yesterday and the previous days because he was not informed by the staff to wear gown, or gloves or wash hands when entering and leaving Resident 59's room. FAM 2 stated, Resident 59 needed to use the bathroom, so he walked outside to the nursing station while still wearing the gown used while he was inside Resident 59's room to ask for assistance from the staffs. During an interview with the Clinical Director (CD) on 7/7/2023 at 12:45 PM, CD stated when visitors arrive to the unit, they check-in at nursing station. CD stated if the resident is in the isolation room, the nurses meet the visitor in front of the resident's room to assist them with putting on PPE. The CD stated, it was Not okay for Resident 59's family to walk out of the Resident 59's room, walk into the hallway wearing PPE that was used while inside the isolation room because of infection control concern. A review of the facility's policy and procedure titled Visitation: A Patient Centered Approach, dated 7/13/2022 indicated, visitors are expected to adhere to the transmission-based (isolation) 555654 Page 13 of 16 555654 07/09/2023 Presbyterian Intercomm Hosp Dp/Snf 12401 Washington Blvd. Whittier, CA 90602

F 0880 Level of Harm - Minimal harm or potential for actual harm guidelines: contact & enteric (through contaminated food and water, by contact with animals or their environments, by contact with the feces of an infected person) precautions- wear gloves and isolation gown. The policy indicated the visitors are expected to perform hand hygiene before entering and when exiting rooms with soap and water. Residents Affected - Few 555654 Page 14 of 16 555654 07/09/2023 Presbyterian Intercomm Hosp Dp/Snf 12401 Washington Blvd. Whittier, CA 90602

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. 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 follow its policy and procedure to maintain and prevent the entrance and harborage (any condition or place where pest can obtain water or food, nest and obtain shelter) of vermin (pests that spread diseases or destroy crops or livestock) and other pest by failing to provide proof of the facility's pest control activities and with presence of vermin in the facility. Residents Affected - Some 1. On 7/7/2023, a live cockroach was observed in the facility hallway, between Resident 61's room and an empty resident room, next to an exit door to stairwell. 2. On 7/9/2023, another live cockroach was observed inside the Shower room [ROOM NUMBER]. This deficient practice resulted in an ineffective pest control program that could result in pest infestation and result in widespread infection and diseases from the pest and cockroaches. Findings: On 7/7/2023 at 8:35 AM, while standing in the hallway (between Resident 61's room and an empty resident room, next to an exit door to stairwell) one live adult sized (about 2.5 centimeters (cm, unit of measure) in length) cockroach was observed in the facility hallway. The [NAME] President of Regulatory Affairs (VPRA) observed the cockroach and stated it was a water bug (oriental cockroach or black cockroaches is a large species of cockroach, adult males being 18-29 millimeters (mm, unit of measure) and adult females being 20-27 mm, it is dark brown or blank in color and has a glossy body) and the staff will clean it up. On 7/9/2023 at 12:24 PM, during an observation with the Life and Safety surveyor in Shower room [ROOM NUMBER], one live adult sized cockroach on the shower floor near the shower drain. The Environmental Safety Officer (ESO) called Environmental Services (EVS) who killed the cockroach. During a telephone interview with the Environmental Services Director (ESD) on 7/9/2023 at 3:00 PM, the ESD stated the facility has a contract with a treatment service company that comes to the facility once a week and as needed. The ESD stated when a waterbug (large cockroach) or any pest is seen, they will document on a log and call out the treatment service company to respond and treat the area. The ESD stated she could not provide a copy of the treatment monitoring log because she was not at the facility. The Clinical Director (CD) and Accrediting & Licensing (AL) staff stated they will try to find a way to retrieve the logs. During a concurrent interview and record review on 7/9/2023 at 6:30 PM, of a paper receipt of a pest treatment, dated 4/2023, the AL staff stated he was unable to provide the treatment monitoring log of the facility's pest treatments. AL stated she could not provide a recent receipt of any pest treatment because the receipts are computerized and could not be accessed without the ESD who was currently not at the facility. 555654 Page 15 of 16 555654 07/09/2023 Presbyterian Intercomm Hosp Dp/Snf 12401 Washington Blvd. Whittier, CA 90602

F 0943 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Based on interview and record review, the facility failed to ensure facility staff received information on abuse prevention as indicated in the facility's policy and procedure. Three of four sampled staff were not able to state the different types of abuse and did not know the time-frame to report abuse allegations of abuse. This deficient practice had the potential for a delay to identify, report and investigate potential allegations of abuse and exposing residents to potential abuse. Findings: During an interview on 7/08/23 at 8:53 AM , CNA2 , CNA 2 was not able to identify all the types of abuse, CNA 2 stated there were 4 types of abuse that the facility had educated her on. CNA - stated she would report abuse allegation immediately but had up to 48 hours to report. During an interview on 7/08/23 at 9:02 AM , Certified Nursing assistant (CNA 1), CAN was not able to identify all the types of abuse, CAN- stated there were 4 types of abuse that the facility had educated her on. CNA 1 - stated she would report abuse allegation immediately but had up to 48 hours to report. During an interview on 7/08/23 at 9:45 AM , housekeeping (HK 1 ), HK1 was not able to identify all the types of abuse, HK1- stated there were 4 types of abuse that the facility had educated her on. HK - stated she was not sure of the time frame to report abuse allegation but knew she had up to 2 days to report. A review of facilities policy and procedure titled Abuse,Neglect, and Misappropriation of property with an approval date of 7/15/2022, indicated All alleged violations immediately but no later than 2 hours if the alleged violation involves abuse or results in serious bodily injury. 2. 24 hours-if the alleged violations does not involve abuse and does not result in serious bodily injury. 555654 Page 16 of 16