Health inspection·December 20, 2024

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 on observation, interview, and record review, the facility failed to adhere to professional standards of practice when Licensed Vocational Nurse 4 (LVN 4) did not record a resident's blood sugar after taking it for one (Resident 185) out of six residents observed during the dining observation task. Residents Affected - Few This failure placed the resident at risk for complications such as hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar) Findings: During a review of Resident 185's Face Sheet (admission record), the Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (high blood sugar). During a review of Resident 185' s Minimum Data Set (MDS, a resident assessment tool), dated 10/10/2024, the MDS indicated Resident 185 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact with skills required for daily decision making. The MDS indicated Resident 185 required set-up help (helper sets up) for eating and personal hygiene. During a review of Resident 185's Physician's Orders, dated 10/01/2022, the order indicated to take Resident 185's blood sugar twice a day at 7:30 a.m. and 4:30 p.m. During a review of Resident 185's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 12/17/2024, indicated LVN 4 took the blood sugar late at 5:49 p.m. on 12/17/2024. During an observation and interview with Resident 185 on 12/17/2024 at 4:20 p.m., observed and spoke with resident in the 3rd floor dining area. When Resident 185 was asked if a licensed nurse took her blood sugar before dinner, Resident 185 stated a licensed nurse has not checked her blood sugar yet. Observed the dining area from 4:20 p.m. until 5:32 p.m. At 5:32 p.m., Resident 185 started eating. During a concurrent record review and interview with LVN 4 on 12/17/24 at 5:35 p.m., LVN 4 stated she had checked Resident 185's blood sugar it at 3:25 p.m. but did not document the blood sugar value anywhere. LVN 4 stated the computer would only allow licensed nurses to document the value one hour before only and not anytime before that. LVN 4 stated she did not write down the value on a sheet of paper to put into the computer when it would allow them to document. LVN 4 stated it is important Page 1 of 26 555846 555846 12/20/2024 Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to document when the blood sugar was taken to avoid confusion. LVN 4 stated she will check Resident 185's blood sugar again. LVN 4 stated she should have documented the blood sugar value when it was originally taken. During an observation on 12/17/2024 at 5:42 p.m., observed LVN 4 wheeling Resident 185 out of the dining room to go to the resident's room to take the blood sugar. During an interview with the Director of Nursing (DON) on 12/18/2024 at 2:40 p.m., the DON stated LVN 4 should have documented the blood sugar after taken or else it is not done. The DON stated licensed nurses must follow the Medication Administration policy in that, although there was a blood sugar taken and no medication given, it is the same principle as with administering medication. The DON stated the blood sugar should be documented right after obtaining and before conducting medication administration for other residents. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, last reviewed 10/16/2024, the P&P indicated the individual administering the medication must initial the resident's MAR on the appropriate line and date for the specific day before administering the next resident's medication. 555846 Page 2 of 26 555846 12/20/2024 Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure a resident was provided a communication device (a device that can help patients communicate with care providers and family using symbols, photos, or illustrations) with the language that the resident was able to understand for one of one sampled resident (Resident 10). Residents Affected - Few This deficient practice had the potential to prevent the resident from communicating with the staff and had the potential to delay receiving appropriate care/treatment the resident needed. Findings: During a review of Resident 10's admission Record, the admission Record indicated the facility originally admitted the resident on 6/7/2021 and readmitted the resident on 9/27/2022 with diagnoses including benign prostatic hyperplasia (prostate gland [gland in the male reproductive system] enlargement that can cause urination difficulty), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood well). The admission Record indicated Resident 10's preferred language was Farsi (foreign language). During a review of Resident 10's Minimum Data Set (MDS - a resident assessment tool), dated 9/13/2024, the MDS indicated the resident had severely impaired cognition (thought processes) and required set-up assistance for eating and oral hygiene, and need supervision for upper body dressing and bed mobility. The MDS indicated Resident 10 needed moderate assistance for showering and lower body dressing. During a concurrent observation and interview on 12/17/2024 at 2:02 p.m., in Resident 10 's room with Certified Nursing Assistant 1 (CNA 1), observed Resident 10 in a wheelchair. The surveyor tried to interview Resident 10, but Resident 10 was not able to communicate in English. The surveyor did not observe any communication board in Resident 10's room or attached to Resident 10's wheelchair. CNA 1 stated that Resident 10 only speaks Farsi, but never saw a communication board in Resident 10's room. During a concurrent interview and record review on 12/18/2024 at 1:53 p.m., with Minimum Data Set Nurse 1 (MDSN 1), reviewed Resident 10's Care Plan (a document that summarizes a resident's needs, goals, and care/treatment) that addressed the resident's language barrier, initiated on 6/8/2021 and revised 12/17/2024. MDSN 1 stated that the care plan indicated that Resident 10 had a communication impairment (having difficulty understanding or expressing thoughts through speaking, writing, or body language) because Resident 10 speaks Farsi. MDSN 1 stated that interventions of the care plan indicated to provide Resident 10 with a communication board. MDSN 1 stated that this deficient practice had the potential to leave Resident 10's needs unmet. During an interview on 12/19/2024 at 12:30 p.m., with the Director of Nursing (DON), the DON stated that the communication board had to be provided to Resident 10 according to Resident 10's care plan interventions. The DON stated if a communication board was not in place, then the staff would not be able to communicate with the resident effectively and address the resident's needs. During a review of the facility's policy and procedure titled, Interpreter Services, last reviewed 555846 Page 3 of 26 555846 12/20/2024 Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335

F 0676 10/16/2024, the policy indicated the facility shall have communication boards for residents who are unable to communicate. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555846 Page 4 of 26 555846 12/20/2024 Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure a resident's low air loss mattress (LALM - designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) was set to the correct setting for one (Resident 480) out of five sample residents investigated under the care area of pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence). Residents Affected - Few This deficient practice had the potential to increase the resident's risk of skin breakdown. Findings: During a review of Resident 480's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility admitted the resident on 12/2/2024 with diagnoses including pressure-induced deep tissue damage of sacral region (a serious injury where the tissues deep beneath the skin over the sacrum [the bony area at the base of the spine] have been damaged due to prolonged pressure). During a review of Resident 480's Minimum Data Set (MDS - a resident assessment tool), dated 12/11/2024, the MDS indicated the resident had severely impaired cognition (the mental process of acquiring knowledge and understanding through thought, experience, and the senses) and required maximal assistance from staff for most activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). The MDS also indicated the resident had one or more unhealed pressure ulcers/injuries and was at risk of developing pressure ulcers/injuries. During a review of Resident 480's physician's orders, an order, dated 12/3/2024, indicated to provide the resident with an LALM for wound management. During a review of Resident 480's care plan (a document that outlines a person's health needs, current medical conditions, and the specific treatments or care required to manage their health) for actual impaired skin integrity related to a sacrococcyx (the bony area at the base of the spine) pressure injury, initiated on 12/13/2024, the care plan indicated the goal that the risk to the resident's skin will be minimized. Among some of the listed interventions included LALM for wound management. On 12/16/2024 at 10 a.m., during an observation, observed Resident 480 asleep in bed. Observed the resident's LALM set to 400 pounds (lbs - unit of measurement). On 12/16/2024 at 10:11 a.m., during a concurrent interview and record review, reviewed Resident 480's current weight and physician orders with Registered Nurse 1 (RN 1). RN 1 stated the resident currently weighed 94 lbs. RN 1 stated although the physician's order did not specify a setting for the LALM, the wound doctor wanted it to be set according to the resident's weight. On 12/16/2024 at 10:12 a.m., during a concurrent observation and interview, Licensed Vocational Nurse 1 (LVN 1) confirmed that Resident 480's LALM mattress was currently set to 400 lbs. LVN 1 stated it should have been set according to the resident's weight, which was 94 lbs. LVN 1 stated the resident currently had an unhealed sacral pressure injury. On 12/20/2024 at 10:41 a.m., during an interview with the Director of Nursing (DON), the DON stated Resident 480's LALM should have been set according to the resident's weight. The DON stated it was 555846 Page 5 of 26 555846 12/20/2024 Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few important for the LALM to be at the correct setting in order to help the resident's wound heal. The DON stated, if not set correctly, then there can be a delay in the healing process, or the resident's wound may not heal at all. During a review of the Operation Manual for the LALM, the Operation Manual indicated to set it according to the correct patient weight. During a review of the facility's policy and procedure titled, Wound and Skin Management, last reviewed and revised on 10/16/2024, the policy and procedure indicated that any resident who has pressure injuries will receive the necessary treatment and services to promote healing, prevent infections, and prevent new injuries from development .Licensed nurses will assure that the interventions [in the care plan] have been implemented .The interdisciplinary team (IDT - a group of professionals from different disciplines or areas of expertise who work collaboratively together to achieve a common goal), licensed nurses, and certified nursing assistants (CNAs) will assure the following preventative measures for residents at risk for skin breakdown - apply pressure redistribution devices for residents in bed based on the resident's individual 555846 Page 6 of 26 555846 12/20/2024 Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335

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. Based on observation, interview, and record review, the facility failed to ensure a licensed nurse did not leave a cup of medications unattended at a resident's bedside for one (Resident 223) out of five sampled residents investigated under the care area of accidents. This deficient practice had the potential for Resident 223 to miss a dose of medications and residents obtaining medication without staff knowledge resulting in accidental ingestion causing harm to residents. Findings: During a review of Resident 223's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility admitted the resident on 3/21/2024 with diagnoses including dysphagia (difficulty swallowing) and dementia (a progressive state of decline in mental abilities). During a review of Resident 223's Minimum Data Set (MDS - a resident assessment tool), dated 10/1/2024, the MDS indicated the resident had moderately impaired cognition (the mental process of acquiring knowledge and understanding through thought, experience, and the senses) and required moderate assistance from staff for most activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). On 12/16/2024 at 10:25 a.m., during an observation, observed Resident 223 in her wheelchair. Observed a cup with eight medications inside on the resident's table. Resident 223 stated she takes her medications by herself all the time. On 12/16/2024 at 10:40 a.m., during an interview, Licensed Vocational Nurse 2 (LVN 2) stated she should not have left the resident's medications unattended at the bedside because the resident was at risk for choking and should have been supervised taking her medications. LVN 2 stated the resident did not have an assessment for self-administration of medications. On 12/19/2024 at 1:47 p.m., during a concurrent interview and record review, reviewed Resident 223's assessments with Minimum Data Set Nurse 1 (MDS Nurse 1). MDS Nurse 1 confirmed that the resident did not have an assessment for self-administration of medications. On 12/20/2024 at 9:52 a.m., during an interview with the Director of Nursing (DON), the DON stated it was important not to leave medications unattended at the resident's bedside because the licensed nurse will not know whether or not the resident actually took the medication. The DON stated, in addition, that other residents would also have unauthorized access to the medications and could possibly experience adverse side effects. During a review of the facility's policy and procedure titled, Medication (Self-Administration), last reviewed and revised on 10/16/2024, the policy and procedure indicated that medications allowed to be left at the bedside may be done only on the specific order of the physician .Medications stored at bedside must not be accessible to other residents who may wander into rooms .Only the medications permitted for self-administration shall be left at bedside. 555846 Page 7 of 26 555846 12/20/2024 Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335

F 0697 Provide safe, appropriate pain management 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 there was documented evidence that non-pharmacological interventions (healthcare treatments that do not primarily involve medication) were attempted prior to administering as needed (PRN) opioid (medications prescribed by doctors to treat persistent or severe pain) pain medications on multiple dates for two (Residents 126 and 65) out of three sampled residents investigated under the care area of pain management. Residents Affected - Some This deficient practice had the potential to place the residents at increased risk of experiencing adverse side effects such as drowsiness, constipation, and decrease in respiration (breathing). Findings: a. During a review of Resident 126's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility admitted the resident on 7/12/2021 and readmitted the resident on 10/26/2022 with diagnoses including hereditary and idiopathic (an illness that isn't connected to any particular cause) neuropathies (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet), ankylosing spondylitis of unspecified sites in spine (a type of arthritis that causes inflammation in the spine and can affect other parts of the body, including the joints, ligaments, and tissues), and chronic pain syndrome (a condition where a person experiences persistent pain that lasts for an extended period [typically more than 3 months], often without a clear identifiable cause, and significantly impacts their daily life). During a review of Resident 126's Minimum Data Set (MDS - a resident assessment tool), dated 10/23/2024, the MDS indicated the resident had intact cognition (the mental process of acquiring knowledge and understanding through thought, experience, and the senses) and required maximal assistance from staff for most activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). The MDS also indicated the resident received PRN pain medication but did not receive non-medication interventions for pain. During a review of Resident 126's care plan (a document that outlines a person's health needs, current medical conditions, and the specific treatments or care required to manage their health) for altered comfort - pain, initiated on 7/13/2021, the care plan indicated to provide for positioning, diversional activities, snacks, back to bed, gentle range of motion (ROM - the extent to which a joint can move in different directions) or massage, and walking for pain relief. On 12/19/2024 at 1:03 p.m., during a concurrent interview and record review, reviewed Resident 126's physician's orders with Minimum Data Set Nurse 1 (MDS Nurse 1). MDS Nurse 1 stated the resident had an order for tramadol (a specific type of narcotic medicine called an opioid that is approved to treat moderate to moderately severe pain in adults) 25 milligrams (mg - unit of measurement) by mouth every 6 hours as needed for pain 6-10/10, ordered on 7/25/2024. Reviewed the resident's 10/2024 Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) with MDS Nurse 1. MDS Nurse 1 confirmed that the resident received tramadol 25 mg on the following dates: 1. 555846 Page 8 of 26 555846 12/20/2024 Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335

F 0697 10/16/2024 at 2:45 p.m. Level of Harm - Minimal harm or potential for actual harm 2. 10/16/2024 at 10:39 p.m. Residents Affected - Some 3. 10/18/2024 at 11:42 a.m. 4. 10/20/2024 at 10:17 p.m. 5. 10/22/2024 at 12:59 p.m. When asked if there was any documentation indicating that non-pharmacological interventions were attempted prior to administering the PRN opioid pain medication, MDS Nurse 1 stated she could not find any documentation indicating that non-pharmacological interventions were attempted prior to the administration of tramadol. MDS Nurse 1 stated it was important to first try non-pharmacological interventions because tramadol was a narcotic (a class of drugs that produce insensibility or stupor due to their depressant effect of the central nervous system), and narcotics had a lot of adverse side effects, so it is better if the resident received less of it. MDS Nurse 1 stated some common side effects of opioids included nausea and vomiting, severe headache, dependence, sedation, and constipation. On 12/20/2024 at 9:50 a.m., during an interview with the Director of Nursing (DON), the DON stated it was important for licensed nurses to first attempt non-pharmacological interventions prior to administering prn opioid pain medication because opioids have a lot of adverse side effects. The DON stated that non-pharmacological interventions should be attempted first because, sometimes, they can help with pain management, and the resident may not even need the medication. The DON stated some possible side effects of opioids included increased drowsiness, constipation, and risk for falls. During a review of the facility's policy and procedure titled, Pain Management, last reviewed and revised on 10/16/2024, the policy and procedure indicated that non-pharmacologic interventions must first be tried. Whether non-pharmacologic methods were tried should be documented on the PRN med sheet. Examples of non-pharmacologic methods include: 1. Distraction 2. Massage 3. 555846 Page 9 of 26 555846 12/20/2024 Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335

F 0697 Ambulation (walking) Level of Harm - Minimal harm or potential for actual harm 4. Repositioning Residents Affected - Some 5. Heat or cold applications 6. Music therapy 7. Provide additional snacks, consider warm milk 8. Provide additional staff time to comfort resident 9. Provide a quiet environment for resident to sleep 10. Ensure no constipation b. During a review of Resident 65's Face Sheet, the Face Sheet indicated the facility admitted the resident on 1/1/2024 and readmitted the resident on 8/20/2024 with diagnoses including cervical spinal stenosis (a narrowing of the spinal canal in the neck that compresses the spinal cord and nerves), polyneuropathy (a condition that occurs when multiple peripheral nerves in the body malfunction at the same time), and chronic pain syndrome. During a review of Resident 65's MDS, dated [DATE], the MDS indicated the resident had intact cognition and required moderate assistance from staff for most ADLs. During a review of Resident 65's care plan for altered comfort - potential for pain, initiated on 1/1/2024, the care plan indicated to provide for positioning, diversional activities, snacks, back to bed, gentle ROM or massage, and walking for pain relief. On 12/19/2024 at 1:23 p.m., during a concurrent interview and record review, reviewed Resident 65's physician's orders with MDS Nurse 1. MDS Nurse 1 stated the resident had an order for hydrocodone-acetaminophen (used to relieve moderate to severe pain) 5-325 mg by mouth twice a day as needed for moderate to severe pain 5-7/10, ordered on 12/3/2024. Reviewed the resident's 12/2024 MAR with MDS 555846 Page 10 of 26 555846 12/20/2024 Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335

F 0697 Nurse 1. MDS Nurse 1 confirmed that the resident received hydrocodone-acetaminophen 5-325 mg on the following dates: Level of Harm - Minimal harm or potential for actual harm 1. Residents Affected - Some 12/5/2024 at 11:54 p.m. 2. 12/6/2024 at 7:58 p.m. 3. 12/7/2024 at 10:13 p.m. 4. 12/11/2024 at 8:41 p.m. When asked if there was any documentation indicating that non-pharmacological interventions were attempted prior to administering the PRN opioid pain medication, MDS Nurse 1 stated she could not find any documentation indicating that non-pharmacological interventions were attempted prior to the administration of hydrocodone-acetaminophen. MDS Nurse 1 stated it was important to first try non-pharmacological interventions because hydrocodone-acetaminophen was a narcotic, and narcotics had a lot of adverse side effects, so it is better if the resident received less of it. MDS Nurse 1 stated some common side effects of opioids included nausea and vomiting, severe headache, dependence, sedation, and constipation. On 12/20/2024 at 9:50 a.m., during an interview with the DON, the DON stated it was important for licensed nurses to first attempt non-pharmacological interventions prior to administering prn opioid pain medication because opioids have a lot of adverse side effects. The DON stated that non-pharmacological interventions should be attempted first because, sometimes, they can help with pain management, and the resident may not even need the medication. The DON stated some possible side effects of opioids included increased drowsiness, constipation, and risk for falls. During a review of the facility's policy and procedure titled, Pain Management, last reviewed and revised on 10/16/2024, the policy and procedure indicated that non-pharmacologic interventions must first be tried. Whether non-pharmacologic methods were tried should be documented on the PRN med sheet. Examples of non-pharmacologic methods include: 1. Distraction 2. Massage 3. 555846 Page 11 of 26 555846 12/20/2024 Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335

F 0697 Ambulation Level of Harm - Minimal harm or potential for actual harm 4. Repositioning Residents Affected - Some 5. Heat or cold applications 6. Music therapy 7. Provide additional snacks, consider warm milk 8. Provide additional staff time to comfort resident 9. Provide a quiet environment for resident to sleep 10. Ensure no constipation 555846 Page 12 of 26 555846 12/20/2024 Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure safe provision of pharmaceutical services to six (6) out of eight (8) sampled residents investigated under the storage of drugs and biologicals (Resident 219, Resident 36, Resident 4, Resident 51, Resident 214 and Resident 111) by failing to: 1. Label Resident 219's opened Lantus-100 (type of insulin [a hormone that works by lowering levels of sugar in the blood]) pen), with an open date to readily identify its beyond use date. This deficient practice had the potential for the for unintentional administration of possibly expired medications for Resident 219. 2. Ensure the opened (in-use) Olopatadine HCl solution (type of eye drops used to treat eye itching) 0.1% (measurement of concentration) vial was discarded after its beyond use date of 11/26/24 from medication cart team B on the second floor. This deficient practice had the potential for the Olopatadine HCl solution 0.1% to lose efficacy and be ineffective in the treatment of Resident 36's condition. 3. Ensure the opened (in-use) Even Care Glucose Control Solution (used to confirm that the meter [blood sugar machine] was working correctly) had a readable open date label to readily identify its beyond use date. This deficient practice had the potential for the Even Care Glucose Control Solution to lose efficacy and to be ineffective in the management of the residents' diabetes mellitus (DM - high blood sugar). 4. Discard a bottle of Opti-Fiber (brand name for a fiber solution to prevent constipation [difficulty emptying the bowels]) for Resident 4, that had expired 10/20/24, but was still in the medication cart. 5. Discard Resident 51's Ativan (a medication given to decrease anxiety [feelings of uneasiness]) blister pack (also known as bubble pack, a card holding usually medicinal tablets or capsules that are individually packaged in a clear plastic case sealed to the card) in which the physician's order ended in November 2024 but, the medication was still in the medication cart. 6. Discard a bottle of Simethicone 80 milligram (mg, a unit of measure for medications) tablets (medication used to relieve too much gas in the stomach and intestines) that had expired 10/2024 but was still in the medication cart. 7. Discard glucose control solution should have been used by 12/05/2024 but was still in the medication cart. These deficient practices had the potential for residents to receive medications that were ineffective, medication that was not intended for the resident, or to have glucose meter reading results to be incorrect. 555846 Page 13 of 26 555846 12/20/2024 Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335

F 0761 8. Ensure eyedrops latanoprost ophthalmic (relating to the eye) and netarsudil ophthalmic solution 0.02% were not in the medication cart past the use by date for Residents 214 and 111. Level of Harm - Minimal harm or potential for actual harm This deficient practice had the potential to result in the residents receiving medications that were ineffective. Residents Affected - Some Findings: 1.During a review of Resident 219's Face Sheet, the Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), type 2 diabetes (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly), and major depressive disorder (a serious mental illness that can cause a persistent low mood, loss of interest, and other symptoms that affect how a person feels, thinks, and acts). During a review of Resident 219's Minimum Data Set (MDS, a resident assessment tool), dated 11/11/2024, the MDS Indicated Resident 219 had intact cognition (undamaged mental abilities, including remembering things, making decisions, concentrating, or learning) .The MDS indicated Resident 219 needed setup help only (helper sets up or cleans up only) with eating and supervision with most activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 219's Physician's Orders, the physician's order indicated an order for Lantus-100 (a medication to lower blood sugar) 18 units (a unit of measurement for medications) subcutaneously (under the skin) at 8:30 PM needed for hypertension (high blood pressure), dated 11/21/2024. During a review of Resident 219's Medication Administration Record, the administration record indicated that Resident 219 received Lantus-100 18 units on following dates: 1. 12/1/2024 at 8:30 p.m. 2. 12/2/2024 at 8:30 p.m. 3. 12/3/2024 at 8:30 p.m. 4. 12/4/2024 at 8:30 p.m. 5. 12/5/2024 at 8:30 p.m. 6. 12/6/2024 at 8:30 p.m. 7. 12/7/2024 at 8: 30 p.m. 8. 12/8/2024 at 8:30 p.m. 9. 12/9/2024 at 8:30 p.m. During a concurrent observation and interview, observed the contents of second floor medication 555846 Page 14 of 26 555846 12/20/2024 Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335

F 0761 Level of Harm - Minimal harm or potential for actual harm cart B with Licensed Vocational Nurse 6 (LVN 6). An opened Lantus-100 pen was observed with no open date and no beyond used date. LVN 6 confirmed that Lantus-100 was not labeled with an open date. LVN 6 confirmed with the facility pharmacist that the Lantus-100 pen had to be discarded 28 days after opening. LVN 6 stated that the Lantus pen should be labeled with an open date to readily identify its beyond use date. Residents Affected - Some 2. During a review of Resident 36's Face Sheet, the Face Sheet indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood well), and glaucoma (an eye condition that occurs when the optic nerve is damaged, which can lead to vision loss or blindness). During a review of Resident 36's Minimum Data Set (MDS, a resident assessment tool), dated 11/20/2024, the MDS Indicated Resident 36 had mildly impaired cognition (a slight decline in mental abilities, memory and completing complex tasks). The MDS further indicated Resident 36 needed setup help only (helper sets up or cleans up only) with eating and moderate assistance with most activities of daily living (ADLactivities such as bathing, dressing and toileting a person performs daily). During a review of Resident 36's Physician's Orders, the physician's order dated 7/31/2024 indicated an order for Olopatadine (type of eye drops used to treat eye itching) 0.1% (measurement of concentration) 1 drop in each eye once a day. During a review of Resident 36's Medication Administration Record, the administration record indicated that Resident 36 received Olopatadine on the following dates: 1. 12/1/2024 at 8:30 a.m. 2. 12/2/2024 at 8:30 a.m. 3. 12/3/2024 at 8:30 a.m. 4. 12/4/2024 at 8:30 a.m. 5. 12/5/2024 at 8:30 a.m. 6. 12/6/2024 at 8:30 a.m. 7. 12/7/2024 at 8:30 a.m. 8. 12/8/2024 at 8:30 a.m. 9. 12/9/2024 at 8:30 a.m. 10. 12/10/2024 at 8:30 a.m. 11. 12/11/2024 at 8:30 a.m. 12. 12/12/2024 at 8:30 a.m. 555846 Page 15 of 26 555846 12/20/2024 Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335

F 0761 13. 12/13/2024 at 8:30 a.m. Level of Harm - Minimal harm or potential for actual harm 14. 12/14/2024 at 8:30 a.m. 15. 12/15/2024 at 8:30 a.m. Residents Affected - Some 16. 12/17/2024 at 8:30 a.m. 17. 12/18/2024 at 8:30 a.m. 18. 12/19/2024 at 8:30 a.m. During a concurrent observation and interview on 12/18/2024 at 9:27 a.m., observed the contents of the second floor medication cart B with Licensed Vocational Nurse 6 (LVN 6). Observed an opened Olopatadine HCl solution with an open date of 10/30 /2024 and a beyond used date of 11/26/2024. LVN 6 confirmed that the Olopatadine HCl solution should have been discarded after 11/6/2024 and should not have been stored in the cart. 3. During a concurrent observation and interview on 12/18/2024 at 9:27 a.m., observed an opened Even Care Glucose Control Solution for a blood sugar machine with an illegible (writing is not clear enough to be read properly) open date. LVN 6 confirmed that she could not read the open date on Even Care Glucose Control Solution. LVN 6 stated she confirmed with the facility pharmacist that the Even Care Glucose Control Solution had to be discarded 90 days after opening. LVN 6 stated that the illegible open date made it impossible to identify the correct ''beyond used date and had the potential to cause ineffective management of the residents' diabetes mellitus. During a review of the Even Care Glucose Solution manual, the manual indicated that newly open bottles of control solution must be marked with an open date on the space provided on the control solution labels and discarded 90 days after opening. During an interview on 12/20/2024 at 9:47 a.m., with the Director of Nursing (DON), the DON stated it was important for medications not to be kept in the cart or used beyond their expiration date because the medication may be ineffective. The DON stated that if a medication was ineffective, then the president's health condition may get worse or remain untreated. The DON stated that the Even Care Glucose Control Solution should have had an open and beyond used date to make sure that the blood sugar level was monitored effectively for residents with DM. During a review of the facility's policy and procedure titled, Drug Storage/Inventory Inspection, last reviewed and revised on 10/16/2024, the policy and procedure indicated that drugs shall not be kept in stock after the expiration date on the label. No unusable drugs shall be stored, distributed, or administered. Unusable drugs include outdated drugs, broken drug packages and damaged drugs, mislabeled drugs, drugs with illegible labels, deteriorated drugs, contaminated drugs, and recalled drugs. All drugs scheduled to expire during the next 60 days of the inspection shall be replaced. 8a. During a review of Resident 214's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility admitted the resident on 5/13/2024 with diagnoses including glaucoma (a group of eye diseases that damage the optic nerve) and peripheral opacity of the cornea of the left eye (when the clear surface of your eye becomes scarred). 555846 Page 16 of 26 555846 12/20/2024 Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335

F 0761 Level of Harm - Minimal harm or potential for actual harm During a review of Resident 214's Minimum Data Set (MDS - a resident assessment tool), dated 11/22/2024, the MDS indicated the resident had intact cognition (the mental process of acquiring knowledge and understanding through thought, experience, and the senses) and required moderate assistance from staff for most activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). Residents Affected - Some During a review of Resident 214's physician's orders, an order, dated 7/26/2024, indicated to administer netarsudil 0.02% eyedrops one drop to the right eye at bedtime for glaucoma. During a review of the Medication Package Insert for netarsudil, the package insert indicated that, after opening, the product may be kept at 36 - 77 degrees Fahrenheit for up to six weeks. On 12/19/2024 at 2:03 p.m., during a concurrent observation and interview, observed the contents of fourth floor medication cart A with Licensed Vocational Nurse 2 (LVN 2). Observed an opened bottle of netarsudil 0.02% eyedrop with an open date of 10/22/2024. LVN 2 stated she confirmed with the facility pharmacist that the netarsudil was good for up to 42 days after opening. LVN 2 stated that the bottle of netarsudil was past the 42 days and should not have been in the cart. On 12/20/2024 at 9:47 a.m., during an interview with the Director of Nursing (DON), the DON stated it was important for medications not to be kept in the cart or used beyond the expiration date because the medication may be ineffective. The DON stated, if a medication was ineffective, then the resident's health condition may get worse or remain untreated. During a review of the facility's policy and procedure titled, Drug Storage/Inventory Inspection, last reviewed and revised on 10/16/2024, the policy and procedure indicated that drugs shall not be kept in stock after the expiration date on the label. No unusable drugs shall be stored, distributed, or administered. Unusable drugs include: outdated drugs, broken drug packages and damaged drugs, mislabeled drugs, drugs with illegible labels, deteriorated drugs, contaminated drugs, and recalled drugs. All drugs scheduled to expire during the next 60 days of the inspection shall be replaced. 8b. During a review of Resident 111's Face Sheet, the Face Sheet indicated the facility originally admitted the resident on 5/9/2016 and readmitted the resident on 11/25/2024 with diagnoses including glaucoma. During a review of Resident 111's MDS, dated [DATE], the MDS indicated the resident had severely impaired cognition and required maximal assistance from staff for most ADLs. During a review of Resident 111's physician's orders, an order, dated 11/25/2024, indicated to administer latanoprost 0.005% one drop to both eyes at bedtime for glaucoma. During a review of the Medication Package Insert for latanoprost, the package insert indicated that, once a bottle is opened for use, it may be stored at room temperature up to 77 degrees Fahrenheit for six weeks. On 12/19/2024 at 2:03 p.m., during a concurrent observation and interview, observed the contents of fourth floor medication cart A with LVN 2. Observed an opened bottle of latanoprost 0.005% eyedrop with an open date of 10/26/2024. LVN 2 confirmed with the pharmacy that the latanoprost was good for up to 42 days after opening. LVN 2 stated that the bottle of latanoprost was past the 42 days and should not have been in the cart. 555846 Page 17 of 26 555846 12/20/2024 Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 12/20/2024 at 9:47 a.m., during an interview with the Director of Nursing (DON), the DON stated it was important for medications not to be kept in the cart or used beyond the expiration date because the medication may be ineffective. The DON stated, if a medication was ineffective, then the resident's health condition may get worse or remain untreated. During a review of the facility's policy and procedure titled, Drug Storage/Inventory Inspection, last reviewed and revised on 10/16/2024, the policy and procedure indicated that drugs shall not be kept in stock after the expiration date on the label. No unusable drugs shall be stored, distributed, or administered. Unusable drugs include: outdated drugs, broken drug packages and damaged drugs, mislabeled drugs, drugs with illegible labels, deteriorated drugs, contaminated drugs, and recalled drugs. All drugs scheduled to expire during the next 60 days of the inspection shall be replaced. 4-7. During a review of Resident 4's Face Sheet (admission record), the Face Sheet indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included hyperlipidemia (high cholesterol). During a review of Resident 4' s Minimum Data Set (MDS, a resident assessment tool), dated 12/12/2024, the MDS indicated Resident 4 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 4 required moderate assistance (helper does less than half the effort) with personal hygiene. During a review of Resident 4's Physician's Order, dated 7/29/2024, the Physician's Orders indicated an order for Benefiber Healthy Shape powder (fiber powder) two teaspoons (a unit of measure for medications), give in eight ounces (a unit of measure for medications) of water as needed once a day for constipation. During a review of Resident 4's Care Plan (CP) for Constipation, initiated 8/25/2022, the CP indicated a goal that the resident will have a bowel movement at least every three days for three months. The care plan indicated an intervention to give medication as needed. During a review of Resident 51's Face Sheet (admission record), the Face Sheet indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included anxiety. During a review of Resident 51' s MDS, dated [DATE], the MDS indicated Resident 51 was moderately impaired in cognition with skills required for daily decision making. The MDS indicated Resident 51 was dependent (helper does all the effort) on staff for dressing and personal hygiene. During a review of Resident 4's Physician's Order, dated 11/12/2024, the Physician's Orders indicated an order for Ativan 0.5 mg tablet by mouth every 12 hours for 14 days (ending 11/26/2024), as needed for general anxiety manifested by agitation/restlessness as evidenced by trying to get out of bed. During a medication cart observation on 12/18/2024 at 3:40 p.m. for Medication Cart 3B, with Licensed Vocational Nurse 3 (LVN 3), on 12/18/2024 at 3:40 p.m., observed Glucose Control Solution with a Beyond-Use Date of 12/05/2024. LVN 3 stated the date indicated is the last day the solution should be used. Observed a bottle of Resident 4's Fiber Powder with an expiration date of 10/20/2024. LVN 3 stated the Fiber Powder should have been removed on 10/20/2024. Observed bottle of Simethicone 80 mg 555846 Page 18 of 26 555846 12/20/2024 Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some tablets with an expiration date indicated:10/2024. LVN 3 stated the medication should have been discarded on 10/2024. Observed the bubble pack for Ativan 0.5 mg tablets for Resident 51. Reviewed Resident 51's Physician's Orders which indicated Ativan 0.5 mg tablets were discontinued on 11/26/2024. LVN 3 stated they should have been removed when they received the order to discontinue the medication. During an interview with Registered Nurse 2 (RN 2) on 12/19/2024 at 10:06 a.m., RN 2 stated Resident 51's Ativan order was an as needed order valid for 14 days only. RN 2 stated when the order ended, the medication should have been removed from the medication cart. RN 2 stated if there is no order for the medication, it should not be in the medication cart. During an interview with the Director of Nursing (DON) on 12/20/2024 at 10:50 a.m., the DON stated it is important to not use the glucose control solution beyond the use by date because the glucose reading could be affected by the outdated solution giving an incorrect glucose reading. During an interview with the DON on 12/19/2024 at 3:58 p.m., the DON stated medications with no order should be removed from the medication cart. The DON stated the staff are to call the pharmacy to come and take the medication from the medication cart. The DON stated this should be done the day the medication was discontinued or by the next day if the pharmacy is not available the day of the order discontinuation. The DON stated this was important to avoid possible medication error such as a resident accidentally receiving the unordered medication. The DON stated it is important for medications to not be used past their expiration date because there was a potential for a resident to receive an ineffective medication. During a review of the facility's policy and procedure (P&P) titled, Disposition of Controlled (medications that the use and possession of are controlled by the federal government) and Non-Controlled Medication (medications such as over the counter or physician prescribed medications that are considered not controlled), last reviewed 10/16/2024, the P&P indicated when a controlled substance is discontinued or expired, the medication shall be stored in an appropriately locked and secure area. The policy indicated the pharmacist is to be notified when controlled substances are discontinued or expired. The policy indicated when a non-controlled medications is discontinued or expired, the medication shall be removed from the medication cart and placed in a secured medication room in the designated containers for disposition. 555846 Page 19 of 26 555846 12/20/2024 Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to meet the nutritional needs for four of 49 sampled residents (Resident 35, Resident 68, Resident 163, and Resident 8) by failing to provide a mechanical soft diet as ordered by the physician by failing to: 1. Ensure kitchen staff placed chopped squash on the tray table for residents on mechanical soft (diet that is ground or chopped for those that have difficulty swallowing or have missing teeth) and dysphagia diets (diet that is chopped or pureed [prepared in a way similar to a pudding] for those with difficulty swallowing) for Resident 35, Resident 68, and Resident 163. 2. Ensure staff did not accidentally serve Resident 8 the incorrect diet when being served lunch. These deficient practices had the potential to place the residents at risk for choking which could then lead to hospitalization and death. Findings: 1.a. During a review of Resident 35's admission Record, the admission Record indicated the facility admitted the resident on 10/9/2021 with diagnoses that included dysphagia (difficulty swallowing). During a review of Resident 35's Minimum Data Set (MDS, a resident assessment tool), dated 10/11/2024, the MDS indicated Resident 35 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 35 was on a mechanically altered diet (diet requiring a change in texture of food or liquids). During a review of Resident 35's Care Plan (a document that summarizes a resident's needs, goals, and care/treatment) for Nutritional Status, initiated 10/11/2024, the care plan indicated an intervention that Resident 35 was prescribed a mechanical soft diet. During a review of Resident 35's Tray Card (a piece of paper that indicates the specific textured meal being served to a resident based on their physician ordered diet, usually placed on the tray beside the meal so staff can check the actual meal being served with what is on the paper), dated 12/18/2024, the Tray Card indicated Resident 35 was prescribed a mechanical soft diet and in bolded writing indicated, chopped roasted squash. 1.b. During a review of Resident 68's admission Record, the admission Record indicated the facility admitted the resident on 7/25/2022 and re-admitted the resident on 9/17/2022 with diagnoses that included dementia (a progressive state of decline in mental abilities). During a review of Resident 68's MDS, dated [DATE], the MDS indicated Resident 68 was severely impaired in cognition with skills required for daily decision making. The MDS indicated Resident 68 was on a mechanically altered diet. During a review of Resident 68's Care Plan for Nutritional Status, initiated 7/31/2024, the care plan indicated an intervention that Resident 68 was prescribed a mechanical soft diet. 555846 Page 20 of 26 555846 12/20/2024 Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335

F 0803 Level of Harm - Minimal harm or potential for actual harm During a review of Resident 68's Tray Card, dated 12/18/2024, the Tray Card indicated Resident 35 was prescribed a mechanical soft diet and in bolded writing indicated, chopped roasted squash. 1.c. During a review of Resident 163's admission Record, the admission Record indicated the facility admitted the resident on 7/19/2023 with diagnoses that included dementia. Residents Affected - Some During a review of Resident 163's MDS, dated [DATE], the MDS indicated Resident 163 was severely impaired in cognition with skills required for daily decision making. The MDS indicated Resident 163 was prescribed a mechanically altered diet. During a review of Resident 163's Care Plan for Nutritional Alteration, initiated 7/25/2024, the care plan indicated a goal that the resident will not have significant weight loss for three months. The care plan indicated an intervention that Resident 163 was prescribed a mechanical soft diet. During a review of Resident 163's Tray Card, dated 12/18/2024, the Tray Card indicated Resident 163 was prescribed a mechanical soft diet and in bolded writing indicated, chopped roasted squash. During a concurrent observation, interview, and record review on 12/18/2024 at 11:55 a.m., with Registered Dietician 1 (RD 1) and Food Services Director (FSD), reviewed the Kitchen Menu Spread Sheet for 12/18/2024 which indicated squash should be chopped for residents on mechanical soft and dysphagia diets. When asked where the chopped squash was for the residents on mechanical soft and dysphagia diets, RD 1 stated that item was not on the tray table. RD 1 stated they would check to see when the item would be sent to the dining area. The FSD stated the cooks did not want to chop the squash because it would fall apart and be mushy. Observed Resident 35, Resident 68, and Resident 163 received their food with squash that had not been chopped. During an interview on 12/18/2024 at 1 p.m., with RD 1, RD 1 stated the residents on the mechanical soft diet should have received the chopped squash because they are to follow the menu so that residents are not put at risk for choking. RD 1 stated chopping the squash ensured the squash skin would be removed. During an interview on 12/18/2024 at 1:14 p.m., with [NAME] 1, [NAME] 1 stated if they cut the squash, it would be too mushy but that the squash should have been chopped. [NAME] 1 stated they ran out of time to chop the squash before transporting from the kitchen to the tray tables in the resident dining areas. [NAME] 1 stated his assistant chops the squash but had not chopped it. [NAME] 1 stated they should have chopped the squash before sending it to the resident dining areas. [NAME] 1 stated they should have followed the menu because it puts residents at risk for choking. [NAME] 1 stated when the squash was first sent to the dining area it was not chopped, but he chopped the next batch and sent that to the 1st floor dining area and the other dining rooms. During an interview on 12/19/2024 at 4:23 p.m., with the Director of Nursing (DON), the DON stated it is important for dietary staff to follow the menu spreadsheet to reduce the risk of possible choking. During a concurrent interview and record review on 12/20/2024 at 10 a.m., with RD 1, reviewed the facility's policy and procedure titled, Menus, and Mechanical Soft Diet, both last reviewed 10/16/2024. RD 1 stated the Dietary Menu Spreadsheet is what the kitchen staff follow in preparing meals indicated by the physician's prescribed order for a resident. The Menu policy indicated menus are written and approved by Registered Dieticians to achieve the dietary standards stated in the Diets manual. 555846 Page 21 of 26 555846 12/20/2024 Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some RD 1 stated the Diets manual refers to the food texture for a certain type of diet such as a mechanical soft diet. The Menu policy indicated therapeutic diets will be provided for each resident in accordance with the prescribed physician order by a person lawfully authorized to give such an order. Reviewed the Mechanical Soft Diet policy with RD 1. RD 1 stated according to the policy, vegetables, such as squash, are to be chopped, well cooked, soft vegetables. RD 1 stated since squash had a skin, it would also apply to the reference tough skins are removed from the Fruits section of the policy. During a review of the facility's policy and procedure titled, Mechanical Soft Diet, last reviewed 10/16/2024, the policy indicated the foods are the same as the Regular diet, but are modified in texture, such as ground or chopped. The policy indicated chopped well cooked soft vegetables. During a review of the facility's policy and procedure titled, Menus, last reviewed 10/16/2024, the policy indicated menus are written and approved by Registered Dieticians to achieve the dietary standards stated in the Diets manual. 2. During a review of Resident 8's admission Record, the admission Record indicated that the facility originally admitted the resident on 12/1/2023 and readmitted the resident on 12/17/2024 with diagnoses including dysphasia, unspecified dementia, and type two diabetes mellitus (a chronic condition that affects the way the body processes blood glucose [sugar]). During a review of Resident 8's MDS dated [DATE], the MDS indicated that the resident's cognitive skills for daily decision making was moderately impaired (decisions poor, cues/supervision required). The MDS indicated that Resident 8 required staff supervision when eating. During a review of Resident 8's Physician Order Report dated 11/1/2024, the order indicated that the resident should be provided with a no added salt (NAS) mechanical soft diet with a nectar thick consistency fluid (fluids that are thicken than regular, still pourable but flows more slowly). During a review of Resident 8's Nutritional assessment dated [DATE], the assessment indicated that the resident's diet was upgraded from pureed diet (when all food has been ground, pressed, and/or strained to a soft, smooth consistency, like a pudding) to mechanical soft diet. During a review of Resident 8's Care Plan for Nutritional Alteration, initiated on 4/1/2024, the care plan indicated a care goal that the resident will not experience significant weight loss for the next three months. The care plan interventions were to provide a mechanical soft diet as ordered by the physician, and to monitor and record meal/supplement intake. During a dining observation on 12/16/2024 at 12:20 p.m., Resident 8 was observed sitting at a table with his wife and eating his lunch. Resident 8's lunch menu ticket indicated NAS-mechanical soft diet with nectar thick liquids. The lunch menu ticket indicated chopped corned beef, chopped [NAME] salad with tomato, chopped cabbage, and chopped boiled potatoes. Observed Resident 8's plate included corn beef, cabbage, and potatoes which were not chopped as per lunch menu ticket. Resident 8 was trying to cut the potatoes, placed the uncut cabbage on the side and did not touch the uncut corn beef. During a concurrent observation and interview on 12/16/2024 at 12:26 p.m., with the facility's Speech-Language Pathologist (SLP), observed Resident 8's lunch tray. The SLP stated that Resident 8's lunch tray was not a mechanical soft diet as ordered but instead a regular diet. The SLP stated that Resident 8 was served his wife's tray, which is not a mechanical soft diet tray. The SLP stated staff 555846 Page 22 of 26 555846 12/20/2024 Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some made a mistake and served Resident 8 a meal which was not chopped, which is a deficient practice. The SLP stated the potential outcome is Resident 8's inability to chew and a potential to choke. During a concurrent interview and record review on 12/18/2024 at 1:40 p.m., with the facility's Registered Dietician 2 (RD 2), reviewed Resident 8's physician orders. RD 2 stated that Resident 8's diet order is mechanical soft diet. RD 2 stated during lunch on 12/16/2024, Resident 8 did not receive mechanical soft diet as ordered by his physician. RD 2 stated that the staff served Resident 8 his wife's lunch tray which was not mechanical soft diet. RD 2 stated the potential outcome of not providing a mechanical soft diet to a resident is the non-compliance with a physician order and an increased risk of choking. During an interview on 12/19/2024 at 1:30 p.m., with the DON, the DON stated that the facility is required to serve meals based on the residents' physician orders. The DON stated Resident 8 was not provided with a mechanical soft diet as ordered by his physician. The DON further stated the potential outcome of not serving mechanical soft to a resident as ordered by the physician is an increased risk of choking and the resident's inability to consume the food which could lead to possible weight loss. During review of the facility's policy and procedure (P&P) titled, Meal Identification, reviewed 10/2024, the P&P indicated that to assist in setting up and serving the correct food trays/diets to residents, the dietary services department will use appropriate identification (e.g., color coded or computer-generated diet cards) to identify the various diets for each resident. Nursing staff shall check food trays for the correct diet before serving the residents. If there is an error, the nurse supervisor will notify the dietary department immediately so that the appropriate food tray can be served. During a review of the facility's P&P titled, Therapeutic Diets, reviewed 10/2024, the P&P indicated that mechanically altered diets, as well as diets modified for medical or nutritional needs, will be considered therapeutic diets. The dietary services manager will establish and use a ray identification system to ensure that each resident receives his or her diet as ordered. 555846 Page 23 of 26 555846 12/20/2024 Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335

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** 2. During a review of Resident 114's admission Record, the admission Record indicated that the facility initially admitted Resident 114 on 4/6/2022 and readmitted the resident on 8/16/2023 with diagnoses including hypertensive chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood well), Alzheimer's disease (a brain disorders that slowly destroys memory and thinking skills and eventually, the ability to carry out the simplest tasks), and 2019-nCov acute respiratory disease (Covid-respiratory illness that causes fever, coughing, and shortness of breath). Residents Affected - Few During a review of Resident 114's Care plan initiated on 8/25/2023 and revised on 07/30/2024, the care plan indicated that Resident 114 had a respiratory system problem related to pneumonia (is an infection that inflames the air sacs [thin-walled structures composed of simple squamous epithelium] in one or both lungs) and being Covid positive. The care plan indicated an intervention to change oxygen tubing and label it every Sunday. During a review of Resident 114's MDS dated [DATE], the MDS indicated that the resident had mildly impaired cognition (a slight decline in mental abilities, memory and completing complex tasks). The MDS further indicated that Resident 114 needed setup assistance for eating, and moderate-to-maximal assistance for showering, oral and toileting hygiene, and was dependent on the assistance of two or more helpers for lower body dressing. During a review of Resident 114's Physician's Order, the Physician's Order indicated an order dated 1/29/2024 for oxygen at 2L (measurement of oxygen flow) via nasal canula as needed (PRN) for shortness of breath. During an observation on 12/16/2024, at 9:27 AM, Resident 114 was observed in the dining room in a wheelchair with oxygen being administered to the resident via nasal canula. During a concurrent observation and interview on 12/16/2024 at 9:30 AM in the dining room with Licensed Vocational Nurse 5 (LVN 5), LVN 5 stated that the oxygen tubing was last changed and labeled on 12/8/2024. LVN 5 stated that according to the facility policy, the oxygen tubing and nasal canula should have been changed on Sunday, 12/15/2024. LVN 5 stated that not changing oxygen tubing and nasal canula every 7 days may lead Resident 114 developing a respiratory infection. During an interview on 12/19/2024 at 8:45 AM with the Infection Preventionist (IP), the IP stated that oxygen tubing had to be changed every Sunday and as needed and labeled with the date when it was last changed to prevent the possibility of Resident 114 developing a respiratory infection. During an interview on 12/19/2024 at 12:30 PM with the Director of Nursing (DON), the DON stated that the oxygen tubing had to be changed every seven days and labeled with date when it was last changed to prevent the possibility of Resident 114 developing a respiratory infection. During a review of the facility Policy and Procedure named Oxygen Management, last reviewed on 10/16/2024, the policy indicated : The oxygen cannula, mask, and tubing shall be dated and changed every seven (7) days and as needed. Based on observation, interview, and record review, the facility failed to ensure two of five sampled residents (Resident 114 and Resident 222) investigated under infection control and respiratory 555846 Page 24 of 26 555846 12/20/2024 Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few care (the health care discipline that specializes in the promotion of optimum cardiopulmonary function and health and wellness) were provided care consistent with professional standards of infection control practice by failing to: 1. Label Resident 222`s oxygen tubing (a flexible, clear hose that delivers oxygen to a patient during oxygen therapy), with the date and time it was last changed. 2. Change Resident 114's oxygen tubing with a nasal canula (a small flexible tube with two prongs that fit inside the nostrils, used to deliver extra oxygen) every seven (7) days. These deficient practices had the potential to place Resident 114 and Resident 222 at increased risk of infection and cause complications associated with oxygen therapy. Findings: 1. During a review of Resident 222's admission Record, the admission Record indicated that the facility admitted the patient on 3/1/2024, with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), history of falling, and anxiety disorder (a condition in which a person has excessive worry and feelings of fear, and uneasiness). During a review of Resident 222`s Minimum Data Set (MDS - a resident assessment tool) dated 10/01/2024, the MDS indicated the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was moderately impaired (decisions poor, cues/supervision required). The MDS indicated Resident 222 was dependent on staff (helper does all of the effort) for showering/bathing, lower body dressing, and toileting hygiene. The MDS further indicated that Resident 222 was using oxygen therapy (a treatment that provides you with supplemental, or extra, oxygen) while a resident at the facility. During a review of Resident 222`s Order Report dated 6/4/2024, the Order Report indicated to administer oxygen at two liters per minute via nasal canula (NC-a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) as needed for shortness of breath (SOB). The Order Report indicated to maintain the oxygen saturation level (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage) greater than 92% at bedtime. During a review of Resident 222`s Order Report dated 8/31/2024, the Order Report indicated to change the oxygen tubing bag every Sunday and label the tube and the bag on Sundays. During a review of Resident 222`s Care Plan (written guide that organizes information about the resident's care) for COPD initiated on 4/3/2024, the care plan indicated a goal that the resident will verbalize ease of respiration every day for 90 days. The care plan indicated interventions to administer oxygen at 2 liters per minute as needed for SOB, to assess and monitor quality of breath, and to elevate the resident`s head of bed to position of comfort. During an observation on 12/16/2024 at 10:40 a.m. inside Resident 222's room, the resident was observed laying on her bed. Resident 222 was receiving oxygen at 2 liters per minute via NC. However, the oxygen tubing did not have a label including the date and time it was last changed. During a concurrent observation and interview on 12/16/2024 at 10:45 a.m. inside Resident 222's room, with Registered Nurse 3 (RN 3), RN 3 stated that Resident 222`s oxygen tubing did not have a 555846 Page 25 of 26 555846 12/20/2024 Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few label with the date and time it was last changed. The RN 3 stated that the facility staff is required to change the oxygen tubing once a week on Sundays. She (RN 3) stated the potential outcome of not changing patient`s oxygen tubing once per week as ordered by the physician is placing the patient at risk for respiratory infection. During an interview on 12/19/2024, at 8:49 a.m., with the facility`s Infection Preventionist (IP), the IP stated that the facility staff is required to change the oxygen tubing once per week on Sundays as ordered by the physician and label the tubing with the date and time it was changed. The IP stated Patient 222`s oxygen tubing was not labeled with the date and time it was last changed, and the potential outcome is the increased risk of infection for Resident 222. During a review of the facility Policy and Procedure named Oxygen Management, last reviewed on 10/16/2024, the policy indicated : The oxygen cannula, mask, and tubing shall be dated and changed every seven (7) days and as needed. 555846 Page 26 of 26