Health inspection·October 6, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. 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 reasonably accommodate Resident 8's physical limitations by providing a soft bell call light within easy reach. This failure had the potential for Resident 8 to be unable to maintain or achieve independent functioning, dignity, and well-being. Residents Affected - Few Findings: A review of Resident 8's face sheet report indicated the resident was admitted to the facility on [DATE] for weakness with diagnsoes including toxic encephalopathy (exposure to toxic substances that changes the brain function or structure), acute respiratory failure (happens suddenly that is caused by a disease or injury to the lungs affecting breathing), cellulitis (a common but serious skin infection) of the right lower limb (leg), and rhabdomyolysis (muscle tissue breakdown damaging the kidneys). A review of Resident 8's Care Plan dated 9/28/2023 indicated a call light was in place. The CP did not indicate Resident 8 refused to use the call light and preferred to scream for assistance. The care plan did not indicate a soft bell call light was in place. During an observation on 10/2/2023 at 8:53 AM, Resident 8 was observed crying. During a concurrent interview Resident 8 stated, I need my pain med, I am in pain. Resident 8 was observed with both hands contracted (curled). Resident 8 was unable to press the call light button to get assistance when needed. During an observation on 10/2/2023 at 8:54 AM, Registered Nurse (RN) 1 was observed coming out of a resident's room. RN 1 was asked to check on Resident 8. RN 1 went into Resident 8's room to inquire resident's needs. Resident 8 was heard requesting for pain medicine. During an interview on 10/2/2023 at 8:55 AM, Resident 8 was asked how was staff aware when help was needed, Resident 8 stated, I just scream and scream until someone comes here. During an observation on 10/2/2023 at 9 AM, RN 1 was observed going into Resident 8's room to administer pain medication. During an interview on 10/2/2023 at 10:05 AM, RN 1 was asked how Resident 8 makes their needs known to staff. RN 1 stated Resident 8 was checked every hour alternately between the RN and the Certified Nursing Assistnat (CNA) assigned to Resident 8. RN 1 added Resident 8 was visited more often, and that during huddle (a group of people having a short discussion) staff were told which residents required additional attention. Page 1 of 18 555927 555927 10/06/2023 Pih Health Good Samaritan Hospital D/P Snf 1225 Wilshire Blvd Los Angeles, CA 90017

F 0558 Level of Harm - Minimal harm or potential for actual harm On 10/2/2023 at 11:03 AM, during an interview, RN 2 was the charge nurse for the day. RN 2 was asked what was the facility's policy regarding accommodating Resident 8 who was not able to use the call light. RN 2 stated the resident was checked hourly by CNA and RN alternately. RN 2 was asked what type of communication system was available for Resident 8 to use when the resident was not able to use the facility's call light system. RN 2 stated soft bell call light. Residents Affected - Few During an observation on 10/2/2023 at 11:13 AM, RN 2 was observed taking a soft bell call light into an unoccupied room to test the device was in good working condition. The device was not working. RN 2 took the same device to another unoccupied room to test the device. The device was not working. During an interview on 10/2/2023 at 11:18 AM, RN 2 was asked what Resident 8 will use to call for help while the soft bell call light was being fixed. RN 2 replied, I don't know. During an interview on 10/2/2023 at 11:58 AM, the Clinical Director (CD) was asked if the unit only had one soft bell call light, the CD stated staff called either Biomed or Maintenance to bring one to the unit. The CD stated they were aware of Resident 8's physical limitations and that Resident 8 screamed and yelled to make needs known. The CD stated staff check on Resident 8 more frequently and that the CNA and the RN alternately check on the resident. A review of the facility's policy and procedure (P&P) titled, Reasonable Accommodations for Individuals with Disabilities, dated 7/13/2022 indicated for individuals with physical disabilities, reasonable accommodations may include but not limited to assisting with activities of daily living. 555927 Page 2 of 18 555927 10/06/2023 Pih Health Good Samaritan Hospital D/P Snf 1225 Wilshire Blvd Los Angeles, CA 90017

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on interview and record review, the facility failed to assist one of six sampled residents (Resident 57) in formulating an Advance Directive (a legal document that tells your doctor your wishes about your health care if you cannot make the decisions yourself). This deficient practice had the potential to inhibit Resident 57's right to communicate his healthcare wishes when he was unable to make or voice those decisions on his own. Findings: A review of Resident 57's Facesheet indicated the facility admitted the resident on 9/9/2023 with diagnoses including neurofibromatosis (a genetic disorder that typically causes benign tumors of the nerves and growths in other parts of the body, including the skin). A review of the clinical record and the Advance Directive Information indicated Resident 57 was provided information on an advance directive on 9/9/2023. A review of the Physician's Order dated 9/9/2023, indicated Resident 57 was to receive a social worker consult due to the resident's request to formulate an advance directive. A review of Resident 57's Minimum Data Set (MDS - an assessment and care screening tool) dated 9/13/2023 indicated the resident was cognitively intact and required supervision and one-person physical assistance with bed mobility, transferring, walking in the room/corridor, locomotion (movement) on/off the unit, dressing, toilet use, and personal hygiene. During a concurrent interview and record review on 10/2/2023 at 2:49 PM, Resident 57's Electronic Health Record (EHR) was reviewed with the Clinical Director (CD). The CD stated Resident 57 did not have an advance directive in his EHR. During a concurrent interview and record review on 10/2/2023 at 2:52 PM, Resident 57's Medical Record Chart (MRC) was reviewed with the CD. The CD stated Resident 57 did not have an advance directive in his MRC. During an interview on 10/3/2023 at 11:45 AM, Resident 57 stated he would like to formulate an advance directive and that he received a copy of his rights but had not spoken to anyone about how to formulate an advance directive. Resident 57 stated that he had not been assisted by staff in formulating an advance directive. During a concurrent interview and record review on 10/5/2023 at 2:40 PM, Resident 57's EHR was reviewed with the Clinical Social Worker (MSW 1). The MSW 1 stated Resident 57 had no advance directive in his EHR. The MSW 1 stated Resident 57 had a physician order for a social worker consult indicating the resident was requesting to formulate an advance directive. The MSW 1 further stated the physician's order for a social worker consult was generated based on an assessment that was conducted by the nurses. The MSW 1 stated the social worker talks to the resident and/or family and provides them with the information to formulate and advance directive. The MSW 1 stated she had not talked to Resident 57, nor did she recall if she spoke to the resident and his family regarding formulating an advance directive. 555927 Page 3 of 18 555927 10/06/2023 Pih Health Good Samaritan Hospital D/P Snf 1225 Wilshire Blvd Los Angeles, CA 90017

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the facility's policy and procedure titled, Advance Directive for Healthcare Information, revised 8/13/2022, indicated the patient has the right to formulate and advance healthcare directive (ADHC) at any time or to review and modify the current ADHC. If any patient wishes to formulate an ADHC the nurse will contact a social worker to provide a blank copy of the ADHC form and educate the patient or patient's family regarding the process. The social worker will document in the Medical Record that an ADHC was provided. The ADHC will be scanned into the Medical Record. 555927 Page 4 of 18 555927 10/06/2023 Pih Health Good Samaritan Hospital D/P Snf 1225 Wilshire Blvd Los Angeles, CA 90017

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. 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 one of three sampled residents (Resident 59) was provided with a Notice of Medicare Non-Coverage (NOMNC - a notice that is provided to beneficiaries that indicates when their Medicare covered services are ending). This deficient practice had the potential to result in the resident not being informed of their coverage end date and not being able to exercise their right to file an appeal. Residents Affected - Few Findings: A review of Resident 59's Facesheet Report indicated the resident was admitted to the facility on [DATE] for a urinary tract infection (UTI - infection that happens when bacteria enter the urinary system and infect the urinary tract). The Facesheet Report indicated Resident 59 was discharged home with home health on 7/10/2023. A review of Resident 59's Minimum Data Set (MDS - an assessment and care screening tool) dated 7/9/2023, indicated the resident was cognitively (ability to think, understand, and reason) intact. The MDS further indicated Resident 59 was totally dependent and required two-person physical assistance with bed mobility, transferring, locomotion (movement) on the unit, and toilet use. The MDS further indicated, Resident 59 required limited assistance and one-person physical assistance with dressing; and supervision and set up help with personal hygiene. A review of Resident 59's Skilled Nursing (SNF) Beneficiary Notification Review form indicated the resident's last covered day for Medicare Part A skilled services was on 7/10/2023. The form indicated the facility initiated the discharge from Medicare part A Services when benefit days were not exhausted. The form indicated Resident 59 was not provided with a NOMNC. The form indicated the explanation of not issued regarding why the NOMNC was not provided to Resident 59. During a concurrent interview and record review on 10/5/2023 at 11:17 AM, the Director of Case Management (DCM) stated Resident 59 was admitted to the facility on [DATE] and was discharged on 7/10/2023. The DCM stated Resident 59's discharge was planned; the resident went home with home health and a bedside commode. The DCM stated Resident 59's last covered day for Medicare Part A services was 7/10/2023 and indicated the resident was not provided with a NOMNC. The DCM stated Resident 59 should have received a NOMNC but was not provided one. The DCM stated Resident 59's, Wife told us he did not have an SNF days remaining so we assumed, but we should have provided the resident with a NOMNC. A review of the Centers for Medicare and Medicaid Services (CMS) undated document titled Form Instructions for the Notice of Medicare Non-Coverage (NOMC) CMS -10123l, indicated a Medicare provider or health plan (Medicare Advantage plans and cost plans, collectively referred to as plans) must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving covered skilled nursing, home health (including psychiatric home health), comprehensive outpatient rehabilitation facility, and hospice services. The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily. 555927 Page 5 of 18 555927 10/06/2023 Pih Health Good Samaritan Hospital D/P Snf 1225 Wilshire Blvd Los Angeles, CA 90017

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete and/or submit the Minimum Data Sets (MDS - a comprehensive standardized assessment and screening tool) within the required time frame for six of 19 sampled residents (Residents 8, 10, 13, 57, 110 and 111). This deficient practice had the potential to negatively affect the provision of necessary care and services for Residents 8, 10, 13, 57, 110 and 111. Findings: a. A review of Resident 8's admission record indicated the facility admitted the resident on 9/2/2023. A review of Resident 8's admission nursing assessment, dated 9/2/2023, indicated the resident was alert and oriented to person place and time, also that Resident 8 denied pain and was using oxygen. The admission nursing assessment did not indicate the nurse assessed the resident's ability to perform activities of daily living (essential and routine activities include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet), the resident's active diagnoses, or Resident 8's recent history with pain. A review of Resident 8's Diagnosis/Procedure History, dated 9/6/2023 indicated the resident's diagnoses included toxic encephalopathy (brain dysfunction caused by toxic exposure), acute kidney failure, right lower leg cellulitis (skin infection) and cardiomyopathy (disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body). b.A review of Resident 10's admission record indicated the facility admitted the resident on 9/12/2023. A review Resident 10's diagnosis/procedure history, dated 9/18/2023 indicated the resident's diagnoses included End Stage Renal Disease (ESRD - the stage of renal impairment that appears irreversible and permanent), requiring dialysis, was immunocompromised (weak immune system) and ischemic cardiomyopathy (heart disease caused by the heart muscle not receiving enough oxygen). c.A review of Resident 13's admission record indicated the facility admitted the resident on 9/9/2023. A review of Resident 13's admission nursing assessment, dated 9/9/2023, indicated the resident was alert, and oriented to person, place and time, also that the resident had an unstageable pressure injury on his sacrum. The nursing assessment did not indicate there was an assessment of his mood, speech, vision, his ability to understand and be understood by others or how he ambulated between locations. A review of Resident 13's diagnosis list dated 9/15/2023, indicated the resident's diagnoses included, ESRD and required dialysis (the process of removing waste products and excess fluid from the body using a machine when the kidneys are not able to do so). d.A review of Resident 57's admission record indicated the facility admitted the resident on 9/9/2023 with a diagnoses including neurofibromatosis (a genetic disorder that typically causes benign 555927 Page 6 of 18 555927 10/06/2023 Pih Health Good Samaritan Hospital D/P Snf 1225 Wilshire Blvd Los Angeles, CA 90017

F 0636 tumors of the nerves and growths in other parts of the body, including the skin). Level of Harm - Minimal harm or potential for actual harm A review of Resident 57's MDS dated [DATE] indicated the resident was cognitively intact and required supervision and one-person physical assistance with bed mobility, transferring, walking in the room/corridor, locomotion (movement) on/off the unit, dressing, toilet use, and personal hygiene. Residents Affected - Many e.A review of Resident 110's admission record indicated the facility admitted the resident on 9/7/2023. A review of Resident 110's initial nursing assessment dated [DATE], indicated the resident was confused without delirium. A review of Resident 110's Diagnosis/Procedure History, dated 9/15/2023, indicated the resident's diagnoses included metabolic encephalopathy and schizophrenia (a serious mental disorder in which people interpret reality abnormally). f.A review of Resident 111's admission record indicated the facility admitted the resident on 9/9/2023. A review of Resident 111's Diagnosis/Procedure History dated 9/15/2023, indicated the resident's diagnoses included diabetes (high blood sugar), left arm cellulitis and acute kidney failure. During an interview on 10/5/2023 at 2:02 PM, the Clinical Director (CD) stated a MDS was done on residents with Medicare Part A. The CD further stated a MDS was not completed for residents with Medi-Cal or Medicare Part B. During a concurrent interview and record review on 10/5/2023 at 3:36 PM, the MDS Coordinator (MDS 1) stated the purpose of the MDS was to collect all information about the resident's stay, it was done to know how to care for the resident and let CMS know what the facility was doing and submit for reimbursement. MDS 1 stated she was supposed to complete an MDS on admission if the resident stays at the facility for more than 14 days. MDS 1 stated she only completes a MDS for residents with Medicare part A. MDS 1 stated she did not complete a MDS for residents with Medicare part B, or residents with Medi-Cal/Medicaid. MDS 1 further stated she completed a MDS for residents with commercial insurance but did not submit the MDS to CMS. MDS 1 stated Residents 8, 10, 13, 110, and 111 did not have an MDS completed. MDS 1 further stated Resident 57 had an MDS completed because the resident had commercial insurance, but indicated it was not submitted to CMS. MDS 1 further stated she did not do a MDS for residents on Medi-Cal because she did not have guidance on how to do it for Medi-Cal residents. A review of the facility's Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual Version 3.0, dated 10/2017, indicated for all reference date. A review of the facility's policy and procedure titled, Resident Assessment Instrument (RAI) Proces,s revised 10/13/2022, indicated the Minimum Data Set (MDS) was a core set of screening, clinical, and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment for all residents of a nursing home certified to participate 555927 Page 7 of 18 555927 10/06/2023 Pih Health Good Samaritan Hospital D/P Snf 1225 Wilshire Blvd Los Angeles, CA 90017

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many in Medicare or Medicaid. Omnibus Budget Reconciliation Act (OBRA) Assessments are Federally mandated and must be completed timely and accurately on all residents regardless of payor source by the assigned due date: admission (required by 14th calendar day of resident's admission) (admission date + 13 calendar days). A review of the CMS document titled, Minimum Data Set Frequency, dated 8/21/2023, indicated the MDS was part of the Federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. Care Area Assessments (CAAs) are part of this process and provide the foundation upon which a resident's individual care plan is formulated. MDS assessments are completed for all residents in certified nursing homes, regardless of source of payment for the individual resident. MDS assessments are required for residents on admission to the nursing facility, periodically, and on discharge. 555927 Page 8 of 18 555927 10/06/2023 Pih Health Good Samaritan Hospital D/P Snf 1225 Wilshire Blvd Los Angeles, CA 90017

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete the Dialysis (the removing of waste, salt, and extra water to prevent build up in the body for residents who have loss of kidney function) Communication Record for one of 19 sampled residents (Resident 13). Residents Affected - Few This deficient practice had a potential to place Resident 13 at risk for a delay in detecting complications related to dialysis including infections, pain, respiratory issues, and bleeding. Cross Reference: F867 Findings: A review of Resident 13's admission Record indicated the facility admitted the resident on 9/9/2023 for swollen feet, seizures (a sudden, uncontrolled burst of electrical activity in the brain), shortness of breath and cough with diagnoses including end stage renal disease (a medical condition in which a person's kidneys stop functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life) and a dependence on renal dialysis. A review of the Hemodialysis (a dialysis procedure that cleans and removes waste from the blood) Plan of Care initiated 9/10/2023, indicated Residents 13 received outpatient hemodialysis on Tuesday, Thursdays, and Saturdays. The Plan of Care further indicated Resident 13 had a left arteriovenous (AV - a connection that's made between an artery and a vein for dialysis access) fistula for hemodialysis access. A review of the Physician's Order dated 9/11/2023 indicated Resident 13 was to receive dialysis routinely. A review of Resident 13's Care Management Initial assessment dated [DATE], indicated Resident 13 stated he received dialysis on Tuesdays, Thursdays, and Saturdays. A review of the Communication Records for September 2023, indicated Resident 13 did not have a dialysis Communication record documented for Saturday, 9/30/2023. A review of Resident 13's Communication Records for October 2023, indicated the resident did not have a dialysis Communication record documented for Tuesday, 10/3/2023. During a concurrent interview and record review on 10/3/2023 at 12 PM, the Dialysis Communication Record form was reviewed with the Accreditation and Licensing Coordinator (AC) 2. The AC 2 stated the Dialysis Communication Record was developed to establish communication with the facility and the dialysis center. The AC 2 indicated the Dialysis Communication Record was filled out by nurses before a resident left the facility and when the resident returned. The AC stated the dialysis center filled out the Dialysis Treatment section and sent it back with the resident to the facility. The AC 2 further indicated the Dialysis Communication Record included an assessment of the dialysis site and vital signs. The AC 2 stated facility staff could document on the Dialysis Communication Record directly or in 555927 Page 9 of 18 555927 10/06/2023 Pih Health Good Samaritan Hospital D/P Snf 1225 Wilshire Blvd Los Angeles, CA 90017

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the resident's Electronic Health Record (HER). Further review of the form indicated the Prior to Dialysis section included: the date and time the resident left the facility, vital signs (heart rate, breathing or respiratory rate, blood pressure, and temperature - body measurements that reflect essential body functions), pain, weight, lab results, changes noted within the past 48 hours, antibiotics, edema (swelling caused by too much fluid trapped in the body's tissues) location, recent fall or significant findings, and assessment of the access site. The Form indicated the Post Dialysis section included: the time the resident returned to the facility, assessment of the access site, and vitals. During a concurrent observation and interview on 10/4/2023 at 8:37 AM, Resident 13 was observed lying in bed with a clean and dry dressing to his left arm. Resident 13 stated he would go to dialysis three times a week and indicated his last dialysis day was 10/3/2023. During a concurrent interview and record review on 10/5/2023 at 11:47 AM, Resident 13's Medical Record, EHR, and Dialysis Communication Records were reviewed with the Clinical Director (CD). The CD stated Resident 13 was going to dialysis every Tuesday, Thursday, and Saturday. The CD stated Resident 13 received dialysis on 9/30/2023 and confirmed there was no Dialysis Communication Record completed in Resident 13's chart or documented in Resident 13's EHR. The CD further confirmed there was no Dialysis Communication Record completed in Resident 13's chart or Electronic Health Record for 10/3/2023. The CD stated the nurses were supposed to ensure they complete the Dialysis Communication Record and send it with the resident to the dialysis center. The CD stated the Dialysis Communication Record included a brief history, assessment of vital signs, assessment of the dialysis access site, and resident information. The CD further stated the dialysis center filled out the Record and returned it to the facility with the resident. The CD stated when the resident returned to the facility, the nurses were supposed to complete the post dialysis section that assessed vital signs and the dialysis access site. The CD stated staff can could also document the information in the resident's EHR. The CD additionally confirmed there was no dialysis access site information documented in Resident 13's EHR on 9/30/2023 and 10/3/2023. The CD stated the Dialysis Communication Record should have been completed to monitor for any changes of condition and ensure there were no complications before and after dialysis. During an interview on 10/5/2023 at 12:57 PM, Registered Nurse (RN) 1 stated she cared for Resident 13. RN 1 stated the purpose of the Dialysis Communication Record was to establish a baseline for the resident before and after dialysis. RN 1 indicated the record had to be documented and sent with the resident to the dialysis center and then documented on when the resident returned to the facility. RN 1 stated the Dialysis Communication Record was used to make sure there were no changes in the resident's alertness level and access site; it was used to monitor the resident for any significant changes and had to be completed before, during, and after dialysis. A review of the facility's Transitional Care Unit (TCU) Dialysis Communication Record Form revised 9/13/2022, indicated the TCU nurse completed the section titled, Prior to Dialysis before sending the resident for dialysis; and completed the section titled Post Dialysis upon the residents return to the TCU. The form indicated the dialysis center would complete the section titled Dialysis Treatment upon completion of dialysis and send the form with the resident back to TCU. 555927 Page 10 of 18 555927 10/06/2023 Pih Health Good Samaritan Hospital D/P Snf 1225 Wilshire Blvd Los Angeles, CA 90017

F 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to post daily actual hours or projected hours worked by the licensed and unlicensed staff providing direct care to the residents per shift and failed to complete the Direct Care Service Hours Per Patient Day (DHPPD - refers to the actual hours of work performed per patient day by a direct caregiver) for 9/3/2023 to 10/4/2023. As a result, staffing information of the unit was not complete and accurate for residents and visitors. Residents Affected - Some Findings: During an interview on 10/5/2023 at 10:53 AM, Clinical Director (CD) stated she was also the unit's Director of Staff Development. During a concurrent observation with the CD, the staffing was posted on the unit and indicated on 10/2/2023 there were three registered nurses and two certified nursing assistants on the day shift (7 AM to 7 PM). the posted staffing also indicated there were two registered nurses, two licensed vocational nurses and two certified nursing assistants on the night shift (7 PM to 7 AM). During a concurrent interview and record review on 10/5/2023 at 3:58 PM, copies of the Daily Staffing Plan from 9/3/2023 to 10/4/2023 were reviewed. The CD stated the copies were of the staff posting for the last month (September 2023). The CD stated the forms did not have the projected or actual working hours of the direct care staff; the forms only listed the actual number of staff working. The CD further stated, Staffing is posted daily to guarantee that we have enough staff to provide care for the residents on the unit. During an interview on 10/6/2023 at 10:47 AM, the CD stated the facility had no policy and procedure regarding the posting of staffing, they just follow the federal guidelines. A review of the federal guidelines indicated for Nurse Staffing Information, the facility must post the following information on a daily basis: (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (C) Certified nurse aides. (iv) Resident census. 555927 Page 11 of 18 555927 10/06/2023 Pih Health Good Samaritan Hospital D/P Snf 1225 Wilshire Blvd Los Angeles, CA 90017

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one sampled residedent (Resident 111) was free of any significant medication errors (incorrect medication administration that could cause the resident discomfort or jeopardizes his/her health and safety) according to professional standards of practice by failing to: Residents Affected - Few -Ensure Resident 111's had ordered parameters for (nifedipine [Procardia] and valsartan [Diovan] for hypertension). -Ensure Licensed Vocational Nurse 1 (LVN 1) did not administer nifedipine [Procardia] or valsartan [Diovan] to Resident 111 without parameters. This deficient practice had the potential to lead to uncontrolled blood pressure which could in turn cause cardiac arrest, stroke, and death. Findings: A review of Resident 111's Face sheet indicated the resident was admitted on [DATE] for right radial (forearm) artery (tubes of muscle that blood flows through) pseudoaneurysm (tear in the outer wall of the tubes of muscles). A review of Resident 111's Diagnosis/Procedure History dated 9/15/2023, indicated diagnoses including acute kidney failure (a condition when kidneys suddenly cannot remove waste from the blood), acute posthemorrhagic anemia (suddenly loses large amounts of blood), gastrointestinal hemorrhage (a type of bleeding in the gut), and Type II diabetes mellitus (a long-lasting condition when the pancreas does not produce enough insulin or when body cannot effectively use the insulin it produces causing blood glucose [sugar] to go high). A review of the Physician's Orders dated 9/10/2023 indicated Resident 111 was to receive: (a) nifedipine [Procardia] XL/CC-extended release 30 milligrams (mg) to be given by mouth every day for hypertension, and (b) valsartan [Diovan] 80 mg to be given by mouth every day for hypertension. The Physician's Orders did not indicate what parameters (a low or high limit in which the blood pressure must fall in between to ensue medication will not cause a fatal drop or rise in blood pressure) needed to be followed during administration. A review of the medication administration record (MAR) dated 9/10/2023, indicated nifedipine and valsartan did not include parameter orders from a physician. During an observation on 10/4/2023 at 8:55 AM, Licensed Vocational Nurse (LVN) 1 was observed checking Resident 111's blood pressure (BP). The BP was 112/62 mm/Hg (millimeters of mercury). During a concurrent interview on 10/4/2023 at 8:56 AM, LVN 1 was asked if there was a parameter order from the physician regarding when to hold the BP medications. LVN 1 responded no, but the facility had a standing order to hold BP medications when systolic (heart has contracted) BP (SBP) was less than 110 mm/Hg. LVN 1 stated there was no written policy with the standing order. During an interview with the Clinical Director (CD) on 10/4/2023 at 9:07 AM, the CD stated not all physicians write parameters on the BP medications. The CD stated writing parameters for BP 555927 Page 12 of 18 555927 10/06/2023 Pih Health Good Samaritan Hospital D/P Snf 1225 Wilshire Blvd Los Angeles, CA 90017

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medications was a work in progress and nurses were taught to watch the BP trend (the range in which the residents BP had been) on residents so interventions could be anticipated. A review of the facility's policy and procedure (P&P) titled, Medication Administration, dated 12/17/2021, indicated the MAR includes patient demographics, drug allergies, medication name and text (parameters/protocols). 555927 Page 13 of 18 555927 10/06/2023 Pih Health Good Samaritan Hospital D/P Snf 1225 Wilshire Blvd Los Angeles, CA 90017

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure all opened food items stored in the freezer was labeled with the name of the food item, open date, and expiration date. This deficient practice placed the 17 facility residents at risk for foodborne illness which could lead to serious infections and death. Findings: During an observation on 10/2/2023 at 8:55 AM with the Operations Manager of Food and Nutrition (OMFN) in the facility's freezer, an opened bag of meat patties was observed. During a concurrent interview the OMFN stated, The item is not in the proper area, the bag should be dated and put into a different container. Right now, it's unidentifiable. We date it to identify it and to know it's shelf life and when the food will expire. Right now, we don't know what it is. A review of the facility's policy and procedure titled, Purchasing, Receiving, and Storing of Food and Supplies - E.83200.024, revised 3/7/2023, indicated all foods held in refrigerated areas were required to be appropriately covered, clearly labeled, if not readily identifiable, and dated. 555927 Page 14 of 18 555927 10/06/2023 Pih Health Good Samaritan Hospital D/P Snf 1225 Wilshire Blvd Los Angeles, CA 90017

F 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on interview and record review, the facility failed to conduct, develop, and revise annually a facility-wide assessment that included the resources needed to competently provide care to their residents. This deficient practice had a potential for the 17 facility residents to not receive comprehensive and specialized care placing them at risk for harm. Findings: During a telephone interview on 10/6/2023 at 10:29 AM, the [NAME] President (VP) 2, stated the facility did not have a facility assessment but had a Community Needs Assessment that addressed the community population the facility cared for. The VP 2 stated the Community Needs Assessment addressed the type of population the facility served, the cultural background, income level, health disparities, and education level. A review of the facility's Community Health Needs Assessment (CHNA) dated 2022, indicated the CHNA identified unmet health needs in the service area, provided information to select priorities for action, targeted geographical areas, and served as the basis for community benefit programs. The CHNA did not include information regarding the resources the facility required to provide the care and services of the identified community and resident needs. The CHNA did not indicate the services the facility provided, the facility's equipment, or the facility's staff and staff competencies. During a concurrent interview and record review on 10/6/2023 at 12:02 PM, the Clinical Director (CD) reviewed the facility's Community Needs assessment dated 2022. The CD stated the Community Needs Assessment was done every three years and covered an assessment of demographics and community needs in the surrounding area the facility serves. The CD stated the Community Needs Assessment provided information on the average age, income level, education level, health disparities, ethnicity, and cultural background of the population surrounding the facility. The CD stated the Community Needs Assessment did not address the facility's resources such as the type of equipment needed, services provided, or the staff present and their competencies. 555927 Page 15 of 18 555927 10/06/2023 Pih Health Good Samaritan Hospital D/P Snf 1225 Wilshire Blvd Los Angeles, CA 90017

F 0851 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on interview record review, the facility failed to ensure their Payroll Based Journal (PBJ - information of the provider's daily staffing hours for the appropriate care of the residents) data had been submitted to the Center for Medicare and Medicaid Services (CMS) for two of four required quarters (1st fiscal quarter due 2/14/2023 and 2nd fiscal quarter due 5/15/2023) in 2023. This deficient practice had the potential to place the 17 facility residents at risk for delay in care, treatment, and services necessary to maintain physical and emotional wellbeing. Findings: A review of the facility's Certification and Survey Provider Enhanced Reporting system (CASPER: Shows the facility percentage and how the facility compares with other facilities in their state and in the nation) indicated no PBJ data had been submitted from 4/1/2023 through 6/30/2023. A review of CMS' website Staffing Data PBJ Submission website (https://www.cms.gov/medicare/quality/nursing-home-improvement/staffing-data-submission) indicated the deadlines for each reporting period were: The 1st fiscal quarter was from 10/1/2022 through 12/31/2022, the indicated submission due date was 2/14/2023. The 2nd fiscal quarter was from 1/1/2023 through 3/31/2023, the indicated submission due date was 5/15/2023. The 3rd fiscal quarter was from 4/1/2023 through 6/30/2023, the indicated submission due date was 8/14/2023. The 4th fiscal quarter was from 7/1/2023 through 9/30/2023 the indicated submission due date was 11/4/2023. A review of the facility provided CMS Submission Report PBJ Submitter Final File Validation Report dated 5/15/2023 at 3:24 PM, indicated the facility attempted to submit the PBJ but the entire file was rejected. A review of the facility provided CMS Submission Report PBJ Submitter Final File Validation Report dated 7/26/2023 at 2:41 PM, indicated the facility attempted to submit the PBJ but the entire file was rejected because the facility identification number was incorrect. The report indicated the authorized user (the facility) did not submit staffing hours. During an interview on 10/5/2023 at 3:58 PM, The Clinical Director (CD) stated, We submit the PBJ quarterly. During an interview on 10/6/2023 at 12:25 PM, the Director of Strategic Partnerships 1 (DSP 1) stated the provides health coverage) however the files for the second and third quarter were rejected due to a discrepancy with the CMS Certification number (CCN: Identification number assigned to 555927 Page 16 of 18 555927 10/06/2023 Pih Health Good Samaritan Hospital D/P Snf 1225 Wilshire Blvd Los Angeles, CA 90017

F 0851 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the facility by CMS) and once the submission window closed the data could not be resubmitted. DSP 1 stated the issue was fixed on 8/3/2023 and confirmed the facility did not resubmit the third quarter PBJ data by the due date of 8/14/2023. A review of the CMS PBJ Policy Manual, dated 6/1/2022, indicated direct care staffing and census data will be collected quarterly, and was required to be timely and accurate. The policy indicated staffing information was required to be an accurate and complete submission of a facility's staffing records. Facilities should run the staffing reports that were available in CASPER to verify the accuracy and completeness of their final submission prior to the submission deadline. CMS will conduct audits to assess a facility's compliance related to this requirement. The policy also indicated facilities that do not meet these requirements will be considered noncompliant and subject to enforcement actions by CMS. Note: If a facility uses a vendor to submit information on behalf of the nursing home, the nursing home was still ultimately responsible for meeting all the requirements. 555927 Page 17 of 18 555927 10/06/2023 Pih Health Good Samaritan Hospital D/P Snf 1225 Wilshire Blvd Los Angeles, CA 90017

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview and record review, the facility's Quality Assessment and Assurance Committee (required to meet at least quarterly to identify issues and to develop and implement plans of action to correct identified deficiencies and to coordinate and evaluate activities to include performance improvement projects) failed to ensure a policy and procedure (a set of rules and/or guidelines that tell facility staff how to care for residents with specific needs) was in place for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). This deficient practice had the potential to inhibit dialysis residents in the facility from receiving high quality care and had the potential to create an unsafe environment for facility residents. Cross Reference: F698 Findings: A review of the facility's quality assurance and quality implementation plan (used to ensure services are meeting quality standards and assuring care reaches a certain level) indicated a policy and procedure for dialysis was not developed and available for review. During an interview on 10/3/2023 at 12:33 PM, [NAME] President (VP) 2 stated the facility did not currently have a dialysis policy and indicated a dialysis policy was still in the process of being developed. 555927 Page 18 of 18