Health inspection·December 3, 2023

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. 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 provide prompt efforts to resolve grievances of residents voiced to the facility through the Resident Council Meetings for two of eighteen sampled residents (resident 9 and Resident 15) who used to attend to a monthly group meeting. Residents Affected - Some This deficient practice resulted in unresolved residents' grievances related to delay in assistance for residents' care needs. Findings: a. During a review of Resident 9's admission record, the admission record indicated Resident 9 was admitted on [DATE], with a diagnosis that included traumatic brain injury (a disruption in the normal function of the brain caused by forceful bump, blow, or jolt to the head or body), tracheostomy dependent (a surgical opening in the neck for an airway), and neurogenic bladder (lack bladder control due to a brain, spinal cord, or nerve problem). During a review of Resident 9's minimum data set ([MDS] a standardized care assessment and care screening tool), dated 11/6/2023, the MDS indicated Resident 9's cognitive skills (thought process) was clear, comprehensive and could understand and be understood by others. The MDS indicated Resident 9 required moderate assistance with activities of daily living such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side). b. During a review of Resident 15's admission record, the admission record indicated Resident 15 was admitted on [DATE] with a diagnosis that included Congestive heart failure (heart muscle has become less able to contract over time or has a mechanical problem that limits its ability to fill with blood), chronic renal failure (involves a gradual loss of kidney function), and muscle weakness (reduced muscle strength). During a review of Resident 15's minimum data set ([MDS] a standardized care assessment and care screening tool), dated 11/21/2023, the MDS indicated Resident 15's cognitive skills (thought process) was clear comprehensive and could understand and be understood by others. The MDS indicated Resident 15 required limited assistance with activities of daily living, such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side). During a review on 12/2/2023 at 10:00 a.m., of Grievance log. There are no indications of grievance log at the facility. Page 1 of 13 555874 555874 12/03/2023 Southern California Hosp at Culver City D/P Snf 3828 Delmas Terrace Culver City, CA 90232

F 0565 Level of Harm - Minimal harm or potential for actual harm During an interview on 12/2/2023 at 9:30 a.m., with Resident 9, Resident 9 stated I used to be the Resident President Council, but, six months ago, we have not had meetings. Resident 9 stated, we used to get together with one or more residents and talked about any problems or changes at the facility. Resident 9 stated, we had not been able to have a meeting because we do not have an activity coordinator. Resident 9 stated, the activity coordinator helps us to arrange the meetings every month. Residents Affected - Some During an interview on 12/2/2023 at 5:22 p.m., with Resident 9 and Resident 15 in their respective rooms, Resident 9 stated the last resident council meeting was 6 months ago. Resident 9 stated, him and Resident 15 would meet once a month. Resident 9 stated, yes it was on a calendar, and we would meet in the activity room. During an interview on 12/2/2023 at 6:00 p.m., with Nurse Manager (NM), the NM stated, Resident 9, Resident 15 and Resident 14 used to get together in resident monthly council meeting. The NM stated, Resident 9 was president of the resident council. The NM stated, we do not have an activity coordinator and the nurses would assist the residents when they want to go to the activity room. During an interview on 12/2/2023 at 6:02 p.m., with Chief Nursing Operator (CNO), the CNO stated, the policy of the facility is to have an activity coordinator to assist residents with meeting but now, we had not hired anybody. During an interview on 12/3/2023 at 6:04 p.m., with NM, the NM stated the importance of residents getting together at least once a month is for them to get social and share any issues or discuss any problems they have with the facility. The residents can voice their concerns to the facility. The NM stated the risk of not having the meetings can cause residents to feel left out and lonely. During a review of the facility's policy and procedure (P&P) titled, Resident Orientation, dated 9/2022, the P&P indicated, each resident, family member, significant and/or concerned others will receive an orientation to the Sub Acute Unit .Quality of Life: Be provided with the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being .Participate in choosing your own activities, schedules and health care and any other aspect affecting your life within the unit .Participate in religious activities and services . 555874 Page 2 of 13 555874 12/03/2023 Southern California Hosp at Culver City D/P Snf 3828 Delmas Terrace Culver City, CA 90232

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure an activity program for five of five sampled residents (Residents 3, 9, 14, 15, and 16) who wanted to participate in activities. Residents Affected - Some The failure to implement a plan to conduct activities in the absence of an activity coordinator placed the residents' mental, psychosocial, and emotional well-being at risk of feeling isolated and depressed. This deficient practice of not having an activity program meant the residents lacked substandard practice and care for their practical well-being. Findings: a. During a review of Resident 3's admission Record (face sheet), indicated an admission to the sub-acute unit on 4/01/2021. During a review, Resident 3's History and Physical (H&P), diagnoses included respiratory failure (the blood does not have enough oxygen) and tracheostomy (an incision to relieve an obstruction to breathing). During a review of Resident 3's Minimum Data Set ([MDS] a comprehensive assessment and care-screening tool), dated 11/16/2023, indicated Resident 3 had limited ability to make concrete requests and ability to understand others. The MDS indicated Resident 3 requires maximal assistance for eating. b. During a review, Resident 16's admission Record (Face Sheet), indicated an admission to the sub-acute on 9/27/2023. During a review, the History and Physical (H&P), dated 9/27/2023, indicated Resident 16 diagnoses included ventilator dependent (a patient that cannot breathe independently), tracheostomy (an opening through the neck into the windpipe to allow air to fill the lungs), left middle cerebral artery disruption ([MCA] a sudden disruption of blood supply to the brain). During a review of Resident 16's Minimum Data Set ([MDS] a comprehensive assessment and care-screening tool), dated 9/29/2023, indicated Resident 16 swallowing and nutritional approaches were tube feeding (a way to provide nutrition when you cannot eat or drink safely by mouth). During an interview on 12/3/2023 at 4:02 p.m. Registered Nurse (RN) 3 stated there is no activity coordinator to conduct daily activities with the residents. RN 3 stated I have not seen anyone engaged in activities with the residents for six months. RN 3 stated there is no oversight to manage if the residents had activities. RN 3 also stated that activities are important so the residents can have stimuli and not feel isolated. During an interview on 12/3/2023 at 4:26 p.m., Registered Nurse (RN) 1 stated there had not been an activity coordinator for more than six months. RN 1 stated no one appointed staff members to do activities with the residents. RN stated I don't recall Nurse Manager (NM) 1 establishing the activities for the Residents. They posted a position for activity coordinator. RN 1 stated the facility would benefit from an activity coordinator. Not having activities could make the residents feel lonely. 555874 Page 3 of 13 555874 12/03/2023 Southern California Hosp at Culver City D/P Snf 3828 Delmas Terrace Culver City, CA 90232

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some RN 1 stated it is important for the residents' emotional well-being because they need company and need to be supported to prevent depression. During an interview on 12/3/2023 at 6:04 p.m., NM 1 stated we haven't had an activity coordinator for more than six months, and we do not have an activity plan for the residents. NM 1 also stated the residents would benefit from having activities, if there were an activity coordinator. Not having an activity plan could make the residents feel isolated. c. During a review, Resident 9's admission record indicated an admission to the facility on 1/14/2022 with a diagnosis that included traumatic brain injury (forceful bump, blow, or jolt to the head or body), tracheostomy dependent (breathing support from a mechanical ventilator), and neurogenic bladder (lack bladder control due to a brain, spinal cord, or nerve problem). During a review of Resident 9's minimum data set ([MDS], a standardized care assessment and care screening tool), dated 11/6/2023, indicated Resident 9's cognitive skills (thought process) were clear and comprehensive, and the resident is understood and understands others. The MDS indicated Resident 9 required moderate assistance with activities of daily living such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair), and bed mobility (how resident moves from lying to turning side to side). During an interview on 12/2/2023 at 9:39 a.m., in the resident's room, Resident 9 stated the activity coordinator was not at the facility anymore, and the nurse manager was trying to get somebody to conduct activities. During an interview on 12/3/2023 at 3:12 p.m., Resident 9 stated since the activity coordination left, I have not had any activities. Resident 9 also noted I do activities by myself. I watch television and movies. The nurses have not asked me if I wanted to do any activities. Usually, the activity coordinator is the person who did activities with us, such as playing Monopoly, cards, dominos, and painting. Resident 9 stated, I do miss those activities. Yes, they need to hire somebody to do activities. Resident 9 stated the nurses are too busy to do those things. d. During a review, Resident 14's admission record indicated an admission to the facility on 3/16/2023 with a diagnosis that included paraplegia (specific pattern of paralysis which can't deliberately control or move muscles), tracheostomy dependent (breathing support from a mechanical ventilator), and schizophrenia (a mental illness that affects how a person thinks, feels, and behaves). During a review of Resident 14's minimum data set ([MDS], a standardized care assessment and care screening tool), dated 11/3/2023, the MDS indicated Resident 14's cognitive skills (thought process) were clear, comprehensive, and able to understand others. The MDS indicated Resident 14 required moderate assistance with activities of daily living, such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair), and bed mobility (how resident moves from lying to turning side to side). e. During a review, Resident 15's admission record indicated an admission to the facility on 6/3/2023 with a diagnosis that included congestive heart failure (heart muscle has become less able to contract over time or has a mechanical problem that limits its ability to fill with blood), chronic renal failure (involves a gradual loss of kidney function), and muscle weakness (reduced muscle strength). 555874 Page 4 of 13 555874 12/03/2023 Southern California Hosp at Culver City D/P Snf 3828 Delmas Terrace Culver City, CA 90232

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review, Resident 15's Minimum Data Set ([MDS], a standardized care assessment and care screening tool), dated 11/21/2023, indicated Resident 15's cognitive skills (thought process) were clear and comprehensive. The resident could understand others. And others could understand the resident. The MDS indicated Resident 15 required limited assistance with activities of daily living, such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair), and bed mobility (how resident moves from lying to turning side to side). During an interview on 12/3/2023 at 3:20 p.m., Resident 15 stated that about six months ago, we used to go to activities three times a week. Resident 15 stated in activities, we used to do painting, play dominos, and color, but the activity coordinator left the facility. Resident 15 stated the nurses do not have time to do activities. Resident 15 stated the nurses had not done any activities since the activity coordinator left. Resident 15 stated that when I get up, sometimes the nurses take me to the activity room, but I stay there alone. I want somebody to do activities and socialize with other residents. Resident 15 stated that Resident 9 and Resident 14 used to be in the activities room and do activities with us, but not anymore. During an interview on 12/03/2023 at 3:45 p.m., RN 3 stated residents can benefit psychologically from having an activity coordinator. RN 3 stated that nurses should have more education and in-services about how activities are part of caring for residents. During an interview, on 12/3/2023 at 4:16 p.m., RN 1 stated the activity coordinator used to be with residents and do birthday and holiday celebrations. RN 1 stated we do not have an activity coordinator at the facility. RN 1 stated nurses tried to do the activities with the residents, but sometimes, the nurses do not have enough time to provide the residents with activities. RN 1 also stated all residents would benefit from having an activity coordinator. It is important to have an activity coordinator because the facility is like the resident's home, and they need company and support to prevent isolation and depression. RN 1 stated the facility should plan on hiring somebody for that position for the resident's well-being. During an interview on 12/3/2023 at 6:09 p.m. NM stated that nurses talked to the resident daily, but we do not have a plan for activities. NM stated nurses are encouraged to go and speak to residents individually. NM noted that the resident would benefit from activities. NM also stated residents are at risk of feeling isolated and depressed by not being able to socialize with other residents. During a review, the facility's policy and procedure titled Accommodation of Needs, dated 1/2022 indicated, The Sub-Acute Unit shall ensure that patients have the right to receive services in the Sub-Acute Unit with reasonable accommodations of individual needs and preferences. During a review, the facility's policy and procedure titled Resident Orientation, dated 9/2022 indicated, Residents will be provided with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Participate in choosing your activities, schedules, health care, and other unit life aspects. Participate in religious activities and services. An activities staff will evaluate your leisure needs, abilities, and interests. We believe your mental, spiritual, and emotional needs to be just as important as your physical ones. Specific activities help you regain as much independence and confidence as possible in your leisure pursuits. 555874 Page 5 of 13 555874 12/03/2023 Southern California Hosp at Culver City D/P Snf 3828 Delmas Terrace Culver City, CA 90232

F 0690 Level of Harm - Minimal harm or potential for actual harm Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review, the facility failed to assess the urine in the indwelling catheter tubing collecting bag for three out of eighteen sampled residents (Residents 9, 11, and 14). Residents Affected - Some 1. Resident 11 had an indwelling catheter (inside the body that drains urine from the bladder into an outside bag) with noticeable sediment (accumulation of white blood cells) that was cloudy and without a privacy bag. 2. Resident 14 had a condom catheter (a soft latex applied over the penis that pushes urine through tubing) with noticeable sediment in the urine tubing with no privacy bag. 3. Resident 9 had an indwelling catheter with noticeable sediment in the urine tubing. This deficient practice placed Residents 9, 11, and 14 at risk for urinary tract infection ([UTI] when bacteria enter the urinary system and infect the urinary tract) or sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues that could lead to malfunctioning of various organs, shock, and death). Findings: 1a. During a review, Resident 11's admission Record (Face Sheet) indicated an admission to the sub-acute on 11/13/2023. During a review, Resident 11's History and Physical (H&P), dated 11/14/2023, indicated diagnoses of transfusion-dependent anemia (the need for continuous blood transfusion), chronic renal insufficiency (the kidneys are damaged and cannot filter blood, and chronic respiratory insufficiency (the lungs cannot take in sufficient oxygen to meet the needs of the cells of the body). During a review, Resident 11's Minimum Data Set ([MDS] a comprehensive assessment and care-screening tool), dated 11/18/2023, indicated Resident 11 could not learn, reason, understand, or make decisions. The MDS also indicated Resident 11 had an indwelling catheter and was always incontinent. During an observation on 12/2/2023 at 9:44 a.m., Resident 11's indwelling catheter had sediment and cloudy urine in the tubing. Resident 11 indwelling catheter bag was without a privacy bag. During a concurrent interview and record review on 12/3/2023 at 1:43 p.m. with Registered Nurse (RN) 3, Resident 11's Assessment and Cares, dated 12/3/2023, was reviewed. The Assessment and Cares indicated on 12/2/2023 that Resident 11's urine was clear and yellow. RN 3 stated he charted the urine, which was clear and yellow. RN 3 stated that when there is sediment, or the indwelling catheter is cloudy, we are to flush the catheter. RN 3 stated I called the doctor on 12/2/2023 at 15:00, and the doctor did not call back, so I endorsed it to the next shift. RN 3 was not able to locate the documentation that the nurse notified the doctor on 12/2/2023 at 15:00. RN 3 stated that cloudy urine and sediment could lead to urinary tract infection ([UTI] when bacteria enter the urinary system and infect the urinary tract), and the UTI could worsen to urosepsis (an infection in the urinary tract that can spread to other areas of the body) if the sediment continues. RN 3 also stated, I was unaware the sub-acute required a privacy bag to cover the indwelling catheter bag. RN 3 also added to 555874 Page 6 of 13 555874 12/03/2023 Southern California Hosp at Culver City D/P Snf 3828 Delmas Terrace Culver City, CA 90232

F 0690 provide Resident 11 with a privacy bag to maintain their dignity. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 12/3/2023 at 2:03 p.m. with RN 1, Resident 11's Assessment and Cares, dated 12/3/2023, indicated on 12/2/2023, Resident 11's urine was yellow and clear. RN 1 stated that the indwelling catheter needs to be assessed daily, and when the urine is cloudy or there is sediment, the nurse needs to notify the doctor. RN 1 stated no cloudy urine or sediments documentation or notification were in the nursing notes on 12/2/2023. There was no documentation that the nurse notified the doctor. RN 1 stated there was no documentation the resident's cloudy urine sample was sent to the lab. RN 1 stated it is important to notify the doctor to prevent the potential of a UTI and to prevent sepsis. RN also 1 stated, the nurses were to place a privacy bag on the indwelling catheters. RN 1 also stated that nurses are here to respect the patient's privacy, such as knocking before entering and placing a privacy bag on Resient 1's indwelling catheter. Residents Affected - Some During a concurrent interview and record review on 12/3/2023 at 6:03 p.m. with Nurse Manager (NM) 1, Resident 11's Assessment and Cares, dated 12/3/2023, indicated on 12/2/2023, Resident 11's urine was yellow and clear. NM 1 stated that if there is sediment in the tubing, the nurse needs to notify the doctor. NM stated I could not find the documentation that the nurse notified the doctor on 12/2/2023. NM stated if the sediment remains, it will put Resident 11 at risk for UTI, and if the UTI worsens, the resident could get sepsis. During an interview on 12/3/2023 at 6:03 p.m., NM 1 stated privacy bags on the indwelling catheter are a courtesy for out-of-the-room residents so others don't see a bag of urine. NM 1 stated there is no policy about covering indwelling catheter bags. NM 1 also stated the privacy bag needs to cover the indwelling catheter so the resident does not experience psychological (the mental and emotional state of a person) harm. During a review of the Care Plan (CP), dated 7/7/2023, the CP indicated the resident had an indwelling catheter. The interventions were to monitor, record, and report to the Medical Doctor (MD) for signs or symptoms of UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. 2b. During a review, Resident 14's admission record indicated an admission to the unit on 3/16/2023 with a diagnosis that included paraplegia (specific pattern of paralysis which can't deliberately control or move muscles), tracheostomy dependent (breathing support from a mechanical ventilator), and schizophrenia (a mental illness that affects how a person thinks, feels, and behaves). During a review of Resident 14's minimum data set ([MDS], a standardized care assessment and care screening tool), dated 11/3/2023, the MDS indicated Resident 14's cognitive skills (thought process) were clear and comprehensive. They could understand others. They also indicated Resident 14 required moderate assistance with activities of daily living, such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair), and bed mobility (how resident moves from lying to turning side to side). During a review of Resident 14's physician orders dated 12/1/2023, the physician orders indicated Resident 14 had an order for a condom catheter to enhance wound healing. During a review of Resident 14's progress notes (PN) dated 11/30/2023, the care plan indicated to evaluate Resident 14 for possible infection/inflammation. There was a recommendation for a urinalysis 555874 Page 7 of 13 555874 12/03/2023 Southern California Hosp at Culver City D/P Snf 3828 Delmas Terrace Culver City, CA 90232

F 0690 Level of Harm - Minimal harm or potential for actual harm (microscopic testing of the urine for disease) and cystoscopy (scope of the urinary tract) to monitor the resident's urine. During an observation on 12/2/2023 at 9:33 a.m., in Resident 14's room with Registered Nurse (RN) 1, no privacy bag was covering the indwelling catheter, and there were sediments in the catheter tubing. Residents Affected - Some During an interview on 12/3/2023 at 1:44 p.m., RN 1 stated Resident 14 had a condom catheter for wound healing. RN 1 stated, Yes, on 12/2/2023, the indwelling catheter tubing had sediments and no privacy bag. RN 1 stated the catheter should be flushed, and we must call the doctor for a urine collection sample. RN 1 stated Resident 14 had a UTI in the past, and we need to prevent Resident 14 from having it again. RN 1 added that the danger of not acting on the cloudy urine could be infection and developing a UTI. RN 1 stated Resident 14 could be at risk of getting sepsis and be transferred to the hospital. RN 1 stated the catheter should be assessed daily by the nurses. RN 1 stated management had told us to put the privacy bag on the indwelling catheter. RN 1 stated that providing an indwelling catheter privacy bag is for residents' dignity. During an interview on 12/3/2023 at 5:45 p.m., the nurse manager (NM) stated there is no facility policy for an indwelling catheter privacy bag. NM stated nurses have to be courteous when patients are outside of the room. The catheter bag must have a privacy bag. NM noted that having a privacy bag on the indwelling catheter makes the residents feel good psychologically, which is very important for some residents. 3c. During a review, Resident 9's admission record indicated an admission to the unit on 1/14/2022, with a diagnosis that included traumatic brain injury (forceful bump, blow, or jolt to the head or body), tracheostomy dependent (breathing support from a mechanical ventilator), and neurogenic bladder (lack bladder control due to a brain, spinal cord, or nerve problem). During a review of Resident 9's minimum data set ([MDS] a standardized care assessment and care screening tool), dated 11/6/2023, indicated Resident 9's cognitive skills (thought process) were clear and comprehensive. They could understand others. The MDS indicated Resident 9 required moderate assistance with activities of daily living such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair), and bed mobility (how resident moves from lying to turning side to side). During a review of Resident 9's physician orders dated 6/7/2022, the physician orders indicated an order for an indwelling urinary catheter to gravity continuous for a neurogenic (urinary conditions in people who lack bladder control due to a brain, spinal cord, or nerve problems) bladder. During a concurrent observation and interview on 12/2/2023 at 9:39 a.m., in Resident 9's room, an indwelling catheter was without a privacy bag, and on the floor and sediments were in the tubing. RN 3 stated the indwelling catheter needs to be flushed, and yes it is sediment in the tubing. RN 3 stated that I would need to check the order of water flushes. During an interview on 12/3/2023 at 3:33 p.m., RN1 stated if Resident 9 had a sediment in the catheter tubing, it must be flushed, and the bag needs to be changed. RN 1 stated the nurse needed to notify the doctor about the cloudy urine and sediments. RN 1 stated I got the order to flush the catheter yesterday, on 12/2/2023. RN 1 stated the importance of taking care of and assessing the catheter to reduce the risk of infection, and Resident 9 could develop UTI and sepsis. 555874 Page 8 of 13 555874 12/03/2023 Southern California Hosp at Culver City D/P Snf 3828 Delmas Terrace Culver City, CA 90232

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 12/3/2023 at 5:45 p.m., NM stated it is the nurses' responsibility to assess the indwelling catheter during every shift. NM stated that in an indwelling assessment, we look for sediment, urine color, and the position of the catheter. NM stated that when sediment is in the indwelling catheter tubing, the nurse must flush the indwelling catheter and change the catheter bag. NM stated that if the sediments continued, we would notify the doctor. NM stated that not checking for sediments could result in a potential infection, such as a UTI. NM stated if left untreated, it can become worse, and Resident 9 would develop sepsis. During a review of the facility's Policy and Procedure (P&P) titled Catheter Care, Routine Daily, dated 1/2014, the P&P indicated, It is the policy of this facility that routine catheter care will be provided twice daily as a part of daily nursing care and as a measure of good nursing practice. It recommended that care be given as part of AM and PM care. Observe urinary drainage for cloudiness, odor, mucus, blood, or sediment. Department leaders and employees are responsible for identifying and maintaining these policies and procedures. 555874 Page 9 of 13 555874 12/03/2023 Southern California Hosp at Culver City D/P Snf 3828 Delmas Terrace Culver City, CA 90232

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure two of 9 sampled residents' (Resident 7 and Resident 15) gastrostomy tube ([GT] tube placed directly into stomach to give direct access for supplemental feeding, hydration, or medicine) feeding formula was labeled with the date and time according to the facility's policy and procedure (P&P). This deficient practice had the potential to result in Resident 7 and Resident 15 receiving tube feeding formula over the expiration or maximum formula hang time (how long a tube feeding formula should hang safely prior to discarding or changing) and could adversely affect the resident's health and wellbeing. Findings: a. During a review of Resident 7's admission Record (Face Sheet), the Face Sheet indicated Resident 7 was admitted on [DATE], with diagnoses including dependence on respiratory (ventilator) status ( unable to wean off a ventilator and breathe independently), Dysphagia (difficulty swallowing) and GT. During a review of Resident 7's physician orders dated 9/13/2023, the physician orders indicated Resident 7 to receive GT feeding of Nephro with Carbsteady @ rate of 50ml/hr. (milliliters/hour) continuously. During a review of Resident 7's Minimum Data Set ([MDS] a standardized care assessment and care screening tool), dated 10/27/2023, the MDS indicated Resident 7 was comatose (in a state of deep unconsciousness for a prolonged or indefinite period due to severe injury or illness). The MDS also indicated Resident 7 was totally dependent on staff with activities of daily living (ADL) such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side). During an observation on 12/2/2023 at 9:33 a.m., in Resident 7's room. Resident 7 was observed with GT feeding infusing and Resident 7's tube feeding formula was not labeled with the date and time formula was hung. During a concurrent observation and interview on 12/2/2023 at 3:20 p.m., with Registered Nurse (RN 1), RN 1 stated Resident 7's GT feeding was not labeled with the date and time the formula was hung. b. During a review of Resident 15's Face Sheet, the Face Sheet indicated Resident 15 was admitted on [DATE] with diagnoses including congestive heart failure (heart muscle has become less able to contract over time or has a mechanical problem that limits its ability to fill with blood), chronic renal failure (involves a gradual loss of kidney function), and muscle weakness (reduced muscle strength). During a review of Resident 15's MDS dated [DATE], the MDS indicated Resident 15's cognitive skills (thought process) was clear and could understand and be understood by others. The MDS also indicated Resident 15 required limited assistance with ADLs such as dressing, toilet use, personal hygiene, 555874 Page 10 of 13 555874 12/03/2023 Southern California Hosp at Culver City D/P Snf 3828 Delmas Terrace Culver City, CA 90232

F 0693 transfer and bed mobility. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 15's physician orders dated 10/6/2023, the physician orders indicated Resident 15 to receive GT feeding of Vital 1.2 @50ml/hr. x 24 hours. Residents Affected - Some During a concurrent observation and interview on 12/2/2023 at 3:53 p.m. with RN 1, in Resident 15's room, RN 1 stated, the nurses forgot to write the time the formula was hung for Resident 15. During an interview on 12/3/2023 at 5:39 p.m., with the Nurse Manager (NM), NM stated, the GT feeding formula lasts 24 hours. NM stated, when hanging a new feeding formula, nurses needed to write the date, time, name, and room number. NM stated GT formula needed to be labeled with hang time to ensure that nurses knew when the bottle needed to be changed. NM also stated, the Residents were at risk of getting diarrhea, vomiting, and hospitalization. During a review of the facility's P&P titled, Gastric Tube Feeding. dated 7/2022 the P&P indicated, each patient fed by gastric tubes receives the appropriate treatment and services to prevent aspiration, pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal pharyngeal ulcers. Patient with gastric tube feeding will be cared for as per Medical Center policy and procedure to assure proper nutrition and prevention of complications. 555874 Page 11 of 13 555874 12/03/2023 Southern California Hosp at Culver City D/P Snf 3828 Delmas Terrace Culver City, CA 90232

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: Residents Affected - Some 1. Ensure stored food were labeled with open date and expiration date. 2. Ensure expired food were not stored in the kitchen and accessible for use in preparing foods in accordance with professional standards for food service safety. This practice had the potential to result in foodborne illnesses which can affect the health and safety of all residents in the facility. Findings: a. During a concurrent observation and interview on 12/2/2023 at 8:00 a.m., of the cereal shelf, there were two (2) open plastic bins with 2 individual cereal boxes without open date and expiration date. On the kitchen counter, a seal plastic container with sesame seeds had no open date and expiration date. On the bread metal shelf, one open bread load had no open date. Kitchen Supervisor (KS) KS stated, there were different persons every time we received products and they forget to place an open date when cereals were removed from the big boxes. KS stated, any open product, must have the orange label indicating the dated it was opened and expiration date. b. During an observation on 12/2/2023 at 8:10 a.m. in the walk-in refrigerator #2, there was a close plastic container with vegetable herb label with expiration date of 11/18/2023. The dry food storage area had one box with 48 pieces of thickened orange juice with expiration date of 10/22/2023. KS stated the person that re-stocked the juice did not check for the products that were expired. During an interview on 12/2/2023 at 10:30 a.m. with Kitchen Aid (KA), the KA stated, it was important to label all products, so we know when it was prepared or when the food was received. The KA stated, if we do not label the food, we won't know when it will be expired and could affect the residents eating the food prepared. During an interview on 12/3/2023 at 12:25 p.m., with KS, the KS stated, usually one employee receives the products delivered and one person stored the products. The KS stated, we must label each product received with the date. We used the first in and first out method (FIFO) when products were stored. The KS stated, when products are taken out from the big boxes, such as the individual cereal boxes, the products must be labeled and use the products that were expiring soon. The KS stated the importance of knowing when the products were received, and its expiration date is to prevent contamination. The KS stated, if the products are compromised, expired, it can cause future medical conditions. KS stated, we cannot put the residents at risk of getting sicker. The KS stated, it was important to follow up with the expiration and to label all products. During a review of the facility's policies and procedures (P&P) titled, Food and Supply Storage, dated 1/2022, the P&P indicated, all food, nonfood items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Cover, label and date unused portion and open package. Complete al sections on a [NAME] orange label. Products are good through the close of business on the date noted on 555874 Page 12 of 13 555874 12/03/2023 Southern California Hosp at Culver City D/P Snf 3828 Delmas Terrace Culver City, CA 90232

F 0812 the label. Date and rotate items: fist in, first out (FIFO). Discard food past the use-by or expiration date. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 555874 Page 13 of 13