Other·February 6, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the Department of Public Health during a Recertification Survey and Entity Reported Incident Investigation. Entity Reported Incident # CA00508496Substantiated (F226 was written) Representing the Department of Public Health: Surveyor ID#: 36205 Surveyor ID#: 14330 Surveyor ID#: 36904 Surveyor ID#: 36925 Surveyor ID#: 36926 Total Resident Census: 98 Total Resident Sample: 20 Randomly Selected Residents: 1 Highest Scope and Severity: G

F221 SS=E RIGHT TO BE FREE FROM PHYSICAL RESTRAINTS CFR(s): 483.13(a)

F221 11/27/2016 The resident has the right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. This REQUIREMENT is not met as evidenced by: LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W8LS11 Facility ID: CA940000079 If continuation sheet 1 of 38 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055170 (X3) DATE SURVEY COMPLETED 10/27/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PICO RIVERA HEALTHCARE CENTER 9140 Verner St Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on observation, interview, and record review, the facility failed to ensure that residents had specific medical symptoms before the use of physical restraints for four of four residents (11, 14, 16, and 17) observed with physical restraints in a total sample of 20 residents. This had the potential for the residents to have reduced independence, functional capacity and quality of life. Findings: a. A review of the Admission Record indicated Resident 14 was admitted to the facility on 8/9/16, with diagnoses that included dementia (a decline of mental abilities such as thinking, reasoning and memory) and diabetes mellitus (a metabolism disorder that affects the body's ability to use blood sugar resulting to high levels of sugar in the blood). A review of the Minimum Data Set ( MDS-a resident assessment and care planning tool), dated 8/16/16, indicated Resident 14 was assessed with short and long term memory recall problems and required extensive assistance (weight bearing support and at times requires full staff performance) in ambulation and transfer. On 10/24/16 at 10:10 a.m., 10/25/16 at 1:15 p.m., and 10/26/16 at 9:00 a.m., Resident 14 was observed sitting quietly with a non self release waist belt around her waist area that was tied to the back of her wheelchair. Resident 14 was observed sitting on a pad alarm (a monitoring device that makes a loud sound when the resident tries to get up and pressure is released from the pad) while in the wheelchair. Resident 14 was alert and Spanish speaking. The assistant activity staff (AA 1) acted as the interpreter for Resident 14. Resident 14 was unable to self- release the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W8LS11 Facility ID: CA940000079 If continuation sheet 2 of 38 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055170 (X3) DATE SURVEY COMPLETED 10/27/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PICO RIVERA HEALTHCARE CENTER 9140 Verner St Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE non self -release waist belt when instructed to do so. Resident 14 stated she did not know why the staff applied the non self -release waist belt to her. On 10/26/16 at 1:15 p.m., the medical record of Resident 14 was reviewed with the director of nursing (DON). Resident 14's physician's order, dated 8/31/16, indicated to apply a non-selfrelease waist belt when Resident 14 was in wheelchair due to attempts to get out of her wheelchair unassisted. The DON stated the pad alarm was applied to prevent Resident 14 from falling while in the wheelchair. There was no documented evidence as to why Resident 14 would require the use of a non-self-release waist belt. The DON stated the Resident 14's medical record did not contain a thorough documentation of the events leading up to the use of the non self -release waist belt to justify Resident 14's behavioral problem of attempting to get out of wheelchair unassisted was due to a specific medical symptom and the use of the physical restraint was medically necessary for Resident 14. b. A review of Resident 11's Admission Record indicated that the facility admitted Resident 11 on 7/6/14 and on 2/11/15, with diagnoses that included dementia, difficulty in walking, generalized muscle weakness, Type 2 diabetes (the body's inability to use insulin the right way), and hypothyroidism (a condition in which the body lacks sufficient thyroid hormone). A review of Resident 11's Minimum Data Set (MDS), dated 8/20/16, indicated that Resident 11 had moderate cognitive (mental ability) impairment that required limited assistance (staff provided guided maneuvering of limbs or other non-weight bearing assistance) with daily living activities. A review of Resident 11's Multidisciplinary FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W8LS11 Facility ID: CA940000079 If continuation sheet 3 of 38 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055170 (X3) DATE SURVEY COMPLETED 10/27/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PICO RIVERA HEALTHCARE CENTER 9140 Verner St Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Progress Record, dated 10/19/15 - 11/21/15, indicated that Resident 11 was up in the wheelchair on several occasions but the record did not indicate that the resident spontaneously stood up from the wheelchair during that time. On 10/19/15, the record indicated that Resident 11 had difficulty in walking. A review of the Order Summary Report, printed on 9/28/16, indicated that on 11/21/15, the physician ordered the application of a selfrelease belt restraint on Resident 11 due to Resident 11 standing up spontaneously while unassisted. A review of the License Nurse Record, dated 11/21/15, 3 p.m. - 11.p.m. shift, indicated that Resident 11 had periods of confusion and had impaired cognition (mental ability). A review of Resident 11's physical restraint assessment, dated 11/21/15, indicated that the diagnosis pertaining to mobility was status-post fall and the medical symptom that warranted the use of a restraint was due to an unsteady gait. At the time of the assessment, Resident 11 was using a personal alarm in bed and in the wheelchair. The assessment indicated that the facility provided less restrictive measures such as the use of body alarm and safety reminders, but were all ineffective due to impaired cognition. Hence, the interdisciplinary team recommended the use of a self-release belt when Resident 11 is up on the wheelchair because the resident had repeatedly attempted to get up from the wheelchair unattended. A review of Resident 11's physical restraint reassessment and reduction tool indicated that on 2/20/16, the continued use of the selfrelease belt restraint order was still in effect. The facility found its use to be appropriate and necessary to manage Resident 11's safety and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W8LS11 Facility ID: CA940000079 If continuation sheet 4 of 38 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055170 (X3) DATE SURVEY COMPLETED 10/27/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PICO RIVERA HEALTHCARE CENTER 9140 Verner St Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE positioning. The diagnosis was "standing up unassisted spontaneously." A review of Resident 11's physical restraint reassessment, dated 5/20/16, indicated that the use of a self-release belt restraint was still necessary for the same reasons they had during the previous reassessment. A review of Resident 11's care plan indicated that a plan of care for the use of a self-release belt restraint while up in the wheelchair was initiated on 8/31/16, with risks that included decreased mobility, decreased physical functioning, contracture development, behavioral problem, incontinence, pressure sores, circulatory problem, dehydration and weight loss. During an interview with the restorative nursing assistant (RNA 1) on 10/26/2016 at 7:55 a.m., RNA 1 stated that Resident 11 was using a self-release belt restraint while she was on her wheelchair. RNA 1 stated that Resident 11 could not remove the restraint while she was on the wheelchair; it prevents her from falling. On 10/26/16 at 8:50 a.m., Resident 11 was observed rolling her wheelchair in the hallway. Resident 11 had a self-release belt restraint attached to her and the wheelchair. A review of a letter from the Centers for Medicare & Medicaid Services (CMS) addressed to the directors of the state agency, dated 6/22/07, indicated that falls do not constitute self-injurious behavior or a medical symptom that warrants the use of a physical restraint. c. A review of Resident 16's Admission Record indicated that the facility admitted Resident 16 on 3/5/15 and on 7/5/16, with diagnoses that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W8LS11 Facility ID: CA940000079 If continuation sheet 5 of 38 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055170 (X3) DATE SURVEY COMPLETED 10/27/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PICO RIVERA HEALTHCARE CENTER 9140 Verner St Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE included urinary tract infection, syncope (a temporary loss of consciousness due to the sudden decline of blood flow to the brain), muscle weakness, difficulty in walking, and hypertension (commonly called high blood pressure, a disease in which blood flows through blood vessels at higher than normal pressure). A review of Resident 16's MDS, dated 8/13/16, indicated that Resident 16 had severe cognitive impairment and was totally dependent in daily living activities. A review of Resident 16's Order Summary Report, printed on 9/28/16, indicated that the physician ordered a lap buddy (a soft laptop cushion that fits snugly between the resident and wheelchair frame) restraint on 7/6/16. The order indicated, "Apply lap buddy while up in the wheelchair for positioning secondary to resident unable to maintain body alignment manifested by leaning forward." On 10/26/16 at 1:15 p.m., Resident 16 was sleeping in her room while sitting on her wheelchair. Resident 16 had a lap buddy restraint on her lap. During an interview with the licensed vocational nurse (LVN 5) on 10/26/16 at 1:15 p.m., LVN 5 stated that she had been working in this facility for seven years. LVN 5 stated that they purposely put a lap buddy restraint on the resident when the resident is on the wheelchair to prevent her from falling. LVN 5 stated that Resident 16 would not be able to remove the lap buddy even if she wanted to. During an interview with LVN 2 and the DON on 10/26/16 at 3 p.m., both staff stated that there was no documented evidence available to indicate that the facility assessed Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W8LS11 Facility ID: CA940000079 If continuation sheet 6 of 38 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055170 (X3) DATE SURVEY COMPLETED 10/27/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PICO RIVERA HEALTHCARE CENTER 9140 Verner St Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 16 for postural problems manifested by leaning forward when on the wheelchair that warrants the use of a lap buddy restraint. The DON stated that they could not provide any documented evidence to indicate that the facility assessed Resident 16 for a specific medical symptom that would justify the continued use of the lap buddy restraint. d. A review of Resident 17's Admission Record indicated the resident was admitted to the facility on 10/20/16, with diagnoses that included dissociative disorder (experiences a disconnection and lack of continuity between thoughts, memories, surroundings, actions and identity), conversion disorder (occurs when a response to stress shows up as a physical disorder), anxiety disorder, difficulty in walking, muscle weakness, major depressive disorder (mood disorder that affects the way a person thinks, feels, & handless daily activities), hypertension (high blood pressure), chronic obstructive pulmonary disease ([COPD] a progressive disease that makes it hard to breath), asthma (a chronic lung disease that inflames and narrows the airways), and anemia (low number of red blood cells). A review of Resident 17's MDS, dated 6/15/16, indicated Resident 17 was sometimes understood, required extensive assistance from one person with transfers, walking, and dressing. The MDS indicated Resident 17 was frequently incontinent (lacking control of bowel and urine) and required assistance to use the toilet. The MDS indicated Resident 17's balance was not steady and only able to stabilize with staff assistance. A review of Resident 17's nurses' notes, dated 10/11/16, 3 p.m. - 11 p.m. shift, indicated Resident 17's physician was called and an order was obtained for a lap buddy and the physician was informed that the alarm on the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W8LS11 Facility ID: CA940000079 If continuation sheet 7 of 38 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055170 (X3) DATE SURVEY COMPLETED 10/27/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PICO RIVERA HEALTHCARE CENTER 9140 Verner St Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE wheelchair was not effective. A review of Resident 17's physician's order, dated 10/11/16 at 6 p.m., indicated an order for a lap buddy while up in the wheelchair to prevent resident from getting up unattended. The order did not indicate the presence of a medical symptom for the lap buddy. The care plan for Resident 17, dated 10/11/16, indicated the resident was required to have a wheelchair with lap tray/lap table for positioning, to prevent the resident from getting up unassisted. A review of Resident 17's physical restraint assessment, dated 10/11/16, indicated that the facility's interdisciplinary team (IDT) recommendations were to use a lap buddy as a restraint for the resident while she was up in her wheelchair, to prevent her from getting up unattended. During an observation on 10/27/16, at 7:30 a.m., Resident 17 was observed sitting up in a wheelchair, next to her bed, with a dark blue lap buddy (a lap cushion used to prevent the resident from standing up from the wheelchair) across her lap. On 10/27/16 at 2:10 p.m., during an interview, the director of nursing (DON) was asked what was the reason for ordering the lap buddy for Resident 17, the DON stated, "She slid from the wheelchair." The DON was asked if there was a medical symptom indicated in Resident 17's clinical record for the use of the lap buddy, the DON turned the pages of Resident 17's clinical record and then stated, "No, I don't see one; I guess we should have thought about it."

F226 SS=D DEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES FORM CMS-2567(02-99) Previous Versions Obsolete

F226 Event ID: W8LS11 11/27/2016 Facility ID: CA940000079 If continuation sheet 8 of 38 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055170 (X3) DATE SURVEY COMPLETED 10/27/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PICO RIVERA HEALTHCARE CENTER 9140 Verner St Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE CFR(s): 483.13(c) The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to immediately remove, from all resident areas, a staff member accused of rough handling one out of 20 sampled residents (Resident 15). This deficient practice had the potential to expose Resident 15 and other residents to unsafe conditions. Findings: On 10/25/16, at 8:11 a.m., during medication pass on the East Station of the facility with licensed vocational nurse (LVN 3), Resident 15 reported she was experiencing pain on her neck and on her right shoulder due to an incident that happened the early morning of 10/25/16. Resident 15 reported to LVN 3 that a female nurse who was changing her adult brief pulled her neck roughly to turn her on her side and told her, "You are too heavy." During an interview at the time, LVN 3 stated that Resident 15 did not usually complain of pain. A review of the facility's certified nursing assistant (CNA) record, dated October 2015, indicated CNA 2 was assigned to Resident 15 on 10/25/16, for the 11p.m. to 7 a.m. shift. On 10/26/16 at 8:30 a.m., CNA 2 was observed working on the East Station by Resident 15's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W8LS11 Facility ID: CA940000079 If continuation sheet 9 of 38 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055170 (X3) DATE SURVEY COMPLETED 10/27/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PICO RIVERA HEALTHCARE CENTER 9140 Verner St Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE room. On 10/26/16, at 10:50 a.m., CNA 2 stated she was assigned to Resident 15 on 10/25/16 on the 11p.m. to 7 a.m., shift. CNA 2 stated the 7 a.m. to 3 p.m. was her usual shift and that on 10/26/16 for the 7 a.m. to 3p.m. shift, she was assigned on the East Station to Rooms 1, 2, and 3. A review of Resident 15's Admission Record indicated Resident 15 was initially admitted to the facility on 9/24/14 and was re-admitted to the facility on 12/17/15. Resident 15's diagnoses included muscle weakness and osteoporosis (weak bones that can easily break). A review on the Resident 15's Minimum Data Set (MDS), a resident assessment and carescreening tool, dated 9/12/16, indicated Resident 15 had severe impairment in cognitive skills (mental ability) for daily decision-making, requiring extensive assistance (weight bearing support and at times requires full staff performance) for bed mobility requiring one person assist and was totally dependent on staff for transfers requiring two persons physical assist. The MDS, dated 9/12/16, indicated Resident 15's weight was 250 pounds (lbs.) and that Resident 15 was always incontinent (having no or insufficient voluntary control over urination or defecation) of urine and bowel. A review of Resident 15's untimed record titled, "Concern Record," dated 10/25/16, indicated that Resident 15 reported an incident to Registered Nurse (RN) 1. Resident 15 reported that a CNA pushed her while being changed in bed in the early morning of 10/25/16 and that she was experiencing back pain. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W8LS11 Facility ID: CA940000079 If continuation sheet 10 of 38 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055170 (X3) DATE SURVEY COMPLETED 10/27/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PICO RIVERA HEALTHCARE CENTER 9140 Verner St Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 15's untitled care plan, dated 12/18/16, and revised on 2/5/16, indicated Resident 15 was at risk for spontaneous pathological stress fracture related to osteoporosis and that the staff's plan was to handle Resident 15 gently and carefully during care. On 10/26/16, at 11:05 a.m., the director of staff development (DSD) stated that she was aware of Resident 15's allegation on 10/25/16. The DSD stated that CNA 2 was assigned to work on 10/26/16 in the East Station to Rooms 1, 2, and 3. Resident 15 was on the East Station. On 10/26/16, at 11:15 a.m., the administrator (ADM) and the director of nurses (DON) stated that RN 1 reported Resident 15's allegation of a CNA being rough with her while changing her adult brief on the early shift of 10/25/16 but not aware of Resident 15's allegation that the nurse told her, "You are too heavy." The ADM stated that she was still investigating and was not certain as to who the perpetrator was even though Resident 15 reported to LVN 3 and RN 1 that the incident occurred on the early morning of 10/25/16. According to the undated facility's policy and procedure titled, "Policy on Patient Abuse and Mistreatment," indicated that if the suspected perpetrator was a staff member, the facility was to immediately place the staff member under administrative suspension for three days or more, depending upon the resolution and/or conclusion of the alleged violations.

F281 SS=D SERVICES PROVIDED MEET PROFESSIONAL STANDARDS CFR(s): 483.20(k)(3)(i)

F281 11/27/2016 The services provided or arranged by the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W8LS11 Facility ID: CA940000079 If continuation sheet 11 of 38 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055170 (X3) DATE SURVEY COMPLETED 10/27/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PICO RIVERA HEALTHCARE CENTER 9140 Verner St Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility must meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to meet professional standards of quality care during medication administration. One out of two residents (random selected resident [RSR] 21), who received medications through a gastrostomy tube (called G-tube, is a tube placed into the stomach through an abdominal wall incision for administration of food, fluids, and medications), received medications without the staff flushing the G-tube with 30 millimeters (ml) of water prior to the administration of the medication. This deficient practice may occlude the tube and could result to an unnecessary replacement of G tube subjecting the resident to another surgical procedure. Findings: A review of RSR 21's Admission Record indicated that the facility admitted RSR 21 on 10/5/16, with diagnoses that included gastrostomy status. During a medication-pass observation on 10/25/16 at 7:30 a.m., the licensed vocational nurse (LVN 1) was observed administering medications through a G-tube to RSR 21. LVN 1 administered the prescribed medications without flushing the G-tube with 30 ml of water prior to giving the medications. LVN 1 stated during the procedure that she forgot to flush the G-tube prior to giving the medications. A review of the facility's policy and procedure titled, "Medication Administration via FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W8LS11 Facility ID: CA940000079 If continuation sheet 12 of 38 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055170 (X3) DATE SURVEY COMPLETED 10/27/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PICO RIVERA HEALTHCARE CENTER 9140 Verner St Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Gastrostomy or Nasogastric Tube," indicated that the enteral feeding tube (same as G tube) should be flushed with at least 30 cubic centimeter (cc, same as ml) of preferable room temperature water before and after medication administration.

F322 SS=D NG TREATMENT/SERVICES - RESTORE EATING SKILLS CFR(s): 483.25(g)(2)

F322 11/27/2016 Based on the comprehensive assessment of a resident, the facility must ensure that -(1) A resident who has been able to eat enough alone or with assistance is not fed by naso gastric tube unless the resident ' s clinical condition demonstrates that use of a naso gastric tube was unavoidable; and (2) A resident who is fed by a naso-gastric or gastrostomy tube receives the appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers and to restore, if possible, normal eating skills. This REQUIREMENT is not met as evidenced by: Based on observations, interviews, and record reviews, the facility failed to ensure the head of the bed (HOB) for one out of 20 sampled residents (Resident 6), who was receiving continuous gastrostomy tube feedings (is a tube placed into the stomach through an abdominal wall incision for administration of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W8LS11 Facility ID: CA940000079 If continuation sheet 13 of 38 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055170 (X3) DATE SURVEY COMPLETED 10/27/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PICO RIVERA HEALTHCARE CENTER 9140 Verner St Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE food, fluids, and medications), was raised at 30 to 45 degrees at all times according to the physician's order. This deficient practice had the potential to cause Resident 6 to aspirate (pulling food or fluids into the airway) which could potentially lead to aspiration pneumonia (inhalation of either oral or gastric contents into the lungs causing swelling of the lungs or infection). Findings: During an observation on 10/26/16, at 7:12 a.m., Resident 6 was lying face up in bed with the head of the bed at approximately less than 20 degree angle. Tube feeding machine was on and was delivering formula labeled Jevity 1.5 (nourishment) at the speed of 50 milliliters per hour. During an interview, on 10/26/16, at 7:12 a.m., licensed vocational nurse (LVN 3) stated that the head of the bed was lower than 20 degree angle, and that it should have been at approximately 30 to 45 degree angle. LVN 3 raised Resident 6's head of the bed at approximately 45 degree angle. A review of Resident 6's Admission Record indicated Resident 6 was initially admitted to the facility on 2/29/16, and was re-admitted on 7/19/16. Resident 6's diagnoses included dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), and dysphagia (difficulty in swallowing). A review of Resident 6's Minimum Data Set (MDS), a resident assessment and carescreening tool, dated 9/26/16, indicated Resident 6 had severe impairment in cognitive skills (mental ability) for daily decision-making FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W8LS11 Facility ID: CA940000079 If continuation sheet 14 of 38 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055170 (X3) DATE SURVEY COMPLETED 10/27/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PICO RIVERA HEALTHCARE CENTER 9140 Verner St Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and was totally dependent on staff for activities of daily living (ADLs). A review of Resident 6's physician's orders, dated 7/19/16, indicated for staff to elevate Resident 6's HOB at 30 to 45 degrees at all times during gastrostomy tube (GT) feedings. A review of Resident 6's untitled care plan, dated 7/20/16, indicated Resident 6 was on GT feeding and was at risk for aspiration and the staff's interventions were to keep the HOB elevated. On 10/26/16 at 7:14 a.m., Registered Nurse (RN) 2 stated that Resident 6 was on GT feedings and that it was important to keep the HOB at 30 to 45 degrees elevated to prevent aspiration, vomiting, or congestion. According to the undated facility's policy and procedure titled, "Enteral Feeding Monitoring," indicated facility required staff to ensure that total enteral feeding (delivery of a nutritionally complete feed, containing protein, carbohydrate, fat, water, minerals and vitamins, directly into the stomach) was administered as ordered.

F323 SS=G FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(h)

F323 11/27/2016 The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W8LS11 Facility ID: CA940000079 If continuation sheet 15 of 38 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055170 (X3) DATE SURVEY COMPLETED 10/27/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PICO RIVERA HEALTHCARE CENTER 9140 Verner St Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE by: Based on observation, interview, and record review, the facility failed to ensure that each resident received supervision to prevent accidents for two of six residents at risk for falls out of a total of 20 sampled residents (Resident 2 and 5). 1a. For Resident 5, the facility failed to provide adequate supervision to meet her needs and other alternatives were not attempted to prevent the resident from falling while sleeping in the wheelchair. These deficient practices resulted in a fall and Resident 5 sustained a fracture (broken bone) of the right wrist, was transferred to a general acute care hospital for treatment, had a surgical procedure to restore the alignment of the wrist bones under general anesthesia (a medically induced coma), and had a decline in the use of her right hand and arm. 1b. For Resident 5, the facility did not place a star sticker by the Resident 5's name outside her door and by her personal areas to alert staff that the resident was a fall risk. 2. For Resident 2, who was assessed as a high fall risk for falls, the facility did not ensure that the resident's sensor pad alarm in his wheelchair was functioning. This deficient practice had the potential to result in a fall. Findings: 1a. On 10/24/16 at 8:53 a.m., during the initial tour of the facility, Resident 5 was observed with a wrist brace on her right hand and wrist. During a concurrent interview, a licensed vocational nurse (LVN 2) stated that Resident 5 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W8LS11 Facility ID: CA940000079 If continuation sheet 16 of 38 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055170 (X3) DATE SURVEY COMPLETED 10/27/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PICO RIVERA HEALTHCARE CENTER 9140 Verner St Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE was on the facility 's falling star program (the facility's falls prevention program) because she had two unwitnessed falls. LVN 2 stated the first unwitnessed fall was on July of 2016 (7/19/16) and the second unwitnessed fall happened in August of 2016 (8/2/16). LVN 2 stated Resident 5 sustained a right wrist fracture after the second fall and the resident was sent to the hospital for treatment. On 10/26/16 at 6:59 a.m., during an interview, LVN 4 stated she was assigned to Resident 5 on 8/2/16. LVN 4 stated that Resident 5 slept in her wheelchair on 8/2/16 and a certified nursing assistant (CNA 1) left Resident 5 unsupervised because she had to answer another resident's call light. LVN 4 stated that Resident 5 needed to be supervised because sleeping in a wheelchair had a greater risk for falls. On 10/27/16 at 6:57 a.m., during an interview, CNA 1 stated she was assigned to Resident 5 on 8/2/16. CNA 1 stated Resident 5 did not like to sleep in her bed and that she slept in her wheelchair. CNA 1 stated LVN 4 was aware that she (CNA 1) left Resident 5 unsupervised (on 8/2/16) to answer a call light for a resident, who was in a different room. On 10/27/16 at 8 a.m., during an interview, Resident 5 stated that she was afraid to walk because of her right arm and because she might hurt herself. The resident stated that she preferred to stay in bed most of the time. A review of Resident 5's admission record (face sheet) indicated the resident was admitted to the facility on 5/24/16 with diagnoses that included muscle weakness, difficulty in walking, major depressive disorder (persistent feeling of sadness and loss of interest) and dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W8LS11 Facility ID: CA940000079 If continuation sheet 17 of 38 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055170 (X3) DATE SURVEY COMPLETED 10/27/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PICO RIVERA HEALTHCARE CENTER 9140 Verner St Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE perform everyday activities). A review of Resident 5's second admission face sheet indicated the resident was readmitted to the facility on 8/10/16 with diagnoses that included muscle weakness, history of falling, and fracture of the lower end of the right radius (one of the two large bones of the forearm). A review on the Resident 5's Minimum Data Set (MDS, a resident assessment and carescreening tool), dated 8/17/16, indicated Resident 5 had severe impairment in cognitive skills for daily decision-making and required extensive assistance (resident involved in the activity; staff provide weight-bearing support) from staff for activities of daily living (ADLs). A review of Resident 5's fall risk assessment, dated 5/24/16, 7/19/16, and 8/2/16, indicated Resident 5 was assessed as being at high risk for falls. Resident 5's fall risk assessment score ranged from 14 to 18 (a score of 8 or more represents a high fall risk). A review of Resident 5's care plan titled, "Falling star program," dated 5/24/16, indicated Resident 5 was at risk for falls related to her "stubborn arrogant behavior," and that the resident preferred to sleep on her wheel chair. The facility staff's interventions included frequent visual monitoring. A review of Resident 5's interdisciplinary team (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) conference record, dated 5/25/16, indicated Resident 5 had a preference to sleep in her wheelchair and that the resident strongly refused to sleep on her bed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W8LS11 Facility ID: CA940000079 If continuation sheet 18 of 38 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055170 (X3) DATE SURVEY COMPLETED 10/27/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PICO RIVERA HEALTHCARE CENTER 9140 Verner St Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 5's "Rehab fall risk assessment," dated 5/25/16, indicated the resident did not demonstrate proper safe sitting and standing balance. A review of Resident 5's joint mobility screening, dated 5/25/16, indicated the resident had full range of motion ([ROM] full movement potential of a joint) to both upper arms and hands. A review of Resident 5's physician orders, dated 5/28/16 at 1p.m., indicated for staff to place Resident 5 on fall precautions. A review of Resident 5's multidisciplinary progress record nursing notes, dated 7/18/16, and timed at 11:15 p.m., and on 7/19/16 at 2:15 a.m., indicated Resident 5 was sleeping in her wheelchair and refused to go to bed. The nursing notes, dated 7/19/16 and timed at 5 a.m., 6:20 a.m., and 6:45 a.m., indicated that Resident 5 was sitting in her wheelchair. A review of the facility's document titled "Interview record," dated 7/19/16 at 7:10 a.m., indicated a Licensed Vocational Nurse (LVN), while making rounds with the oncoming shift, found Resident 5 on the floor. The interview record notes indicated the LVN noted that Resident 5 got up by herself and fell. A review of an untimed Resident 5's interdisciplinary team conference group note, dated 7/19/16, indicated the resident had an unwitnessed fall and was found lying on the floor next to her bed. A review of Resident 5's rehabilitation screen post fall incident screen report, dated 7/19/16, indicated that on 7/19/16, Resident 5's wheelchair was unlocked while Resident 5 attempted to transfer and fell. The report FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W8LS11 Facility ID: CA940000079 If continuation sheet 19 of 38 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055170 (X3) DATE SURVEY COMPLETED 10/27/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PICO RIVERA HEALTHCARE CENTER 9140 Verner St Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicated that the therapist assessed Resident 5 and noted that Resident 5 needed to be supervised when transferring due to Resident 5's inability to demonstrate proper safe sitting and standing balance. A review of Resident 5's physical therapist (PT) discharge summary notes, dated 5/25/16 to 8/1/16, indicated that on 5/25/16 Resident 5 ambulated on level surfaces with a distance of 30 feet using a two wheeled walker with supervision. The discharge summary note, dated 7/31/16, indicated that Resident 5 was able to ambulate a distance 150 feet using two wheeled walker with supervision. The discharge summary note, dated 8/1/16, indicated Resident 5 was able to ambulate a distance of 125 feet using a two wheeled walker with supervision. A review of Resident 5's licensed progress notes, dated 8/2/16, indicated Resident 5 was sleeping in her wheelchair at 12 a.m. to 1:09 a.m. At 1:10 a.m., a certified nursing assistant (CNA 1), who was assigned to supervise Resident 5, was called to a different room to answer a call light. A review of the licensed progress notes, dated 8/2/16, and timed at 1:15 a.m., indicated that a facility staff heard a noise and found Resident 5 sitting on the floor with her right wrist swollen and with a small cut that was bleeding. The progress notes indicated that Resident 5 was assisted to bed and her right wrist was immobilized. A review of the facility's document titled, "Interview Record," dated 8/2/16 at 1:30 a.m., indicated Resident 5 was sleeping and tried to get up and fell, and hit her head and right wrist. A review of the Resident 5's undated nursing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W8LS11 Facility ID: CA940000079 If continuation sheet 20 of 38 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055170 (X3) DATE SURVEY COMPLETED 10/27/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PICO RIVERA HEALTHCARE CENTER 9140 Verner St Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE post-fall assessment and follow-up form, dated 8/2/16, indicated the resident fell trying to stand from the wheelchair in her room. A review of the licensed progress notes, dated 8/2/16, and timed at 2:20 a.m. indicated Resident 5 was experiencing severe pain on a scale of 8 out of 10 (zero represents no pain at all while 10 represents the worst imaginable pain) to her right wrist. At 2:45 a.m., the resident was transferred to a general acute care hospital (GACH). A review of Resident 5's GACH record titled, "Consultation," and dated 8/2/16, indicated Resident 5 had a mechanical fall at the nursing home while attempting to sit down on an unlocked wheelchair. Resident 5 presented to the emergency room (ER) with multiple skin lacerations on the forearms, acute head injury, rib fracture, chest pain, and a right wrist x-ray showed bilateral distal radius and ulnar (both bones in the forearm situated away from the center of the body) fractures. A review of the Resident 5's GACH record titled, "Department of Diagnostic Imaging," dated 8/2/16, indicated Resident 5's right wrist had a displaced angulated fracture (fracture in which the fragments of bone are at angles to one another) of the distal radius and a complex fracture (a fracture with significant soft tissue injury) of the distal ulna. A review of Resident 5's GACH record titled "Operative report," and dated 8/3/16, indicated Resident 5's had a right wrist open type I fracture (open fracture with a puncture wound of less than or equal to 1 centimeter in length with minimal soft tissue injury, minimal wound contamination or muscle crushing). The operative report indicated Resident 5 underwent general anesthesia (medically FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W8LS11 Facility ID: CA940000079 If continuation sheet 21 of 38 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055170 (X3) DATE SURVEY COMPLETED 10/27/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PICO RIVERA HEALTHCARE CENTER 9140 Verner St Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE induced coma and loss of protective reflexes resulting from the administration of one or more general anesthetic agents) and underwent an irrigation and debridement ([I&D] the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) of open fracture with closed reduction (a method for treating fractures that is performed without opening the skin) and casting of a distal radius fracture. A review of Resident 5's GACH record titled "Discharge Summary," indicated the resident had an acute head injury, rib fracture, and a right arm fracture. Resident 5 was discharge back to the facility on 8/10/16. A review of Resident 5's joint mobility screening dated 10/7/16, indicated Resident 5 had severe (greater than 50%) loss to her right upper extremity (UE). On 10/27/16 at 9:09 a.m., during an interview, a registered nurse (RN 1) stated that he was aware that Resident 5 liked to sleep in her wheelchair because Resident 5 was more comfortable in her wheelchair. RN 1 stated that Resident 5 was at a higher risk for falling because sleeping in her wheelchair was not safe. RN 1 stated that the licensed nurses did not create a care plan or an investigation for Resident 5 sleeping on a wheelchair. RN 1 stated Resident 5 had a regular mattress prior to the falls. RN 1 stated that there were no other alternatives offered to Resident 5 other than sleeping on her wheelchair. RN 1 stated that the facility did not use a visual monitoring document and that Resident 5 needed frequent supervision. On 10/27/16 at 10:05 a.m., during an interview, an occupational therapist (OT 1) stated that after readmission to the facility, Resident 5 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W8LS11 Facility ID: CA940000079 If continuation sheet 22 of 38 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055170 (X3) DATE SURVEY COMPLETED 10/27/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PICO RIVERA HEALTHCARE CENTER 9140 Verner St Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE preferred not to walk anymore because of her right arm and the resident instead spent most of her time in her bed. On 10/27/16 at 12:07 p.m., during an interview, the director of nurses (DON) and LVN 2 stated that they were aware that Resident 5 preferred to sleep in her wheelchair since her initial admission to the facility until 8/2/16. The DON and LVN 2 stated that Resident 5 was at higher risk for falling due to sleeping in her wheelchair and she needed frequent monitoring. The DON and LVN 2 stated that there was no care plan or reasons explored as to why Resident 5's preferred to sleep in her wheelchair prior the falls. The DON and LVN 2 stated that there were no other alternatives for Resident 5 other than for Resident 5 to sleep in her wheelchair. During the interview, the DON stated that the facility did not have any system in place on visual monitoring for residents at risk for falls. The DON and LVN 2 stated that Resident 5 liked to stay in bed most of the time after her readmission to the facility. A review of the facility's undated policy and procedure titled, "Fall," indicated the facility required staff to develop a comprehensive care plan to prevent any recurrences and to meet Resident's specific needs. According to the Centers for Medicare and Medicaid Services (CMS) falls are the leading cause of injury, morbidity, and mortality in older adults and that a previous fall, especially a recent fall, recurrent falls, and falls with significant injury are the most important predictors of risk for future falls and injurious falls and that facilities are required to mark yes on the MDS if a resident had a fall in the month preceding the resident's entry date. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W8LS11 Facility ID: CA940000079 If continuation sheet 23 of 38 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055170 (X3) DATE SURVEY COMPLETED 10/27/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PICO RIVERA HEALTHCARE CENTER 9140 Verner St Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1b. On 10/24/16 at 8:53 a.m., during the interview, LVN 2 stated that there was no star sticker next to Resident 5's name outside her room or in her room. LVN 2 stated there should have been a star sticker outside Resident 5's room since the resident was on the falling star program. A review of facility's undated policy and procedure titled, "Falling star program," indicated facility required to staff to place a "Colorful Star," in personal resident areas. 2. On 10/24/16 at 8:45 a.m., during a tour of the facility with RN 1, Resident 2 was observed propelling his wheelchair inside his room. When RN 1 assisted resident in standing up from the wheelchair, the wheelchair sensor pad alarm did not function. On 10/24/16 at 8:55 am, an interview was conducted with RN 1. RN 1 stated Resident 2 was at risk for falls and the sensor pad alarm on the wheelchair should have been functioning when the resident got up from the wheelchair. RN 1 stated the sensor pad alarm would help prevent falls by alerting the staff whenever the resident got up from the wheelchair unassisted. RN 1 called the maintenance department staff to fix the sensor pad alarm. A review of Resident 2's clinical record indicated the resident was admitted to the facility on 1/17/14 and was readmitted on 4/25/16 with diagnoses that included essential hypertension (elevated blood pressure), heart failure (condition when the heart is unable to pump sufficiently to maintain blood flow to meet the body's needs), unspecified osteoarthritis (type of joint disease that results from breakdown of joint cartilage [connective tissue] FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W8LS11 Facility ID: CA940000079 If continuation sheet 24 of 38 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055170 (X3) DATE SURVEY COMPLETED 10/27/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PICO RIVERA HEALTHCARE CENTER 9140 Verner St Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and underlying bone), and history of falling. A review of Resident 2's Minimum Data Set (MDS - a standardized assessment and care planning tool), dated 8/13/16, indicated the resident's cognition was intact. Resident 2 required limited assistance (resident highly involved in activity, staff provide guided maneuvering of limbs or other non-weight bearing assistance) to extensive assistance in performing activities of daily living. Resident 2 normally used a walker and wheelchair for ambulation. A review of Resident 2's Fall Risk Assessment, dated 8/24/16, indicated a score of 8 or more represented a high fall risk and Resident 2 scored 21. The assessment form indicated Resident 2 had intermittent confusion/poor safety awareness. A review of Resident 2's care plan titled, "Sensor Pad Alarm," dated 6/13/16, indicated the resident required sensor pad alarm when in wheelchair and in bed due to the spontaneous act/behavior of trying to get up unassisted. Resident 2's care plan indicated the alarm is used to alert staff for any unsafe mobility. One of the approaches was to monitor the alarm for good working condition and proper placement as needed. A review of Resident 2's care plan with focus on Super Star Program (the facility's falls prevention program), dated 3/27/14 and revised on 8/23/15, indicated the resident was at risk for falls related to decreased strength/endurance, unsteady gait, cognitive impairment and history of falls. One of the interventions indicated personal alarm when up in wheelchair and in bed to alert staff of unsafe transfer. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W8LS11 Facility ID: CA940000079 If continuation sheet 25 of 38 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055170 (X3) DATE SURVEY COMPLETED 10/27/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PICO RIVERA HEALTHCARE CENTER 9140 Verner St Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 2's physician's order, dated 6/13/16, indicated to apply a sensor pad alarm when the resident is up in a wheelchair and in bed due to the resident's spontaneous act/behavior of getting up unassisted. A review of the facility's incident log indicated Resident 2 had the history of falling on 3/16/14, 1/18/15 and 3/20/15. A review of the facility's undated policy and procedure titled, "Accident Reduction: Useful interventions," indicated the following useful interventions should help reduce accidents and prevent injuries: Personal bed/chair alarm.

F328 SS=D TREATMENT/CARE FOR SPECIAL NEEDS CFR(s): 483.25(k)

F328 11/27/2016 The facility must ensure that residents receive proper treatment and care for the following special services: Injections; Parenteral and enteral fluids; Colostomy, ureterostomy, or ileostomy care; Tracheostomy care; Tracheal suctioning; Respiratory care; Foot care; and Prostheses. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to: 1. Follow physician's oxygen treatment orders for two (Resident 6 and Resident 8) out of 20 sampled residents. Resident 6 and Resident 8 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W8LS11 Facility ID: CA940000079 If continuation sheet 26 of 38 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055170 (X3) DATE SURVEY COMPLETED 10/27/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PICO RIVERA HEALTHCARE CENTER 9140 Verner St Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE were receiving higher oxygen concentrations than what the physician ordered. 2. Label Resident 6's oxygen equipment. Resident 6's normal saline (salt solution) humidifier was not labeled with the date it was first opened/used. 3. Develop a care plan for Resident 6 who was receiving oxygen treatment. These deficient practices had the potential to harm the residents by increasing air flow, which could damage the lungs and make it difficult for Resident 6 and Resident 8 to breath and had the potential for Resident 6 to receive an expired normal saline humidifier, and had the potential for Resident 6 to receive inadequate nursing care interventions. Findings: a. On 10/24/16 at 8:55 a.m., during the initial tour of the facility, Resident 8 was observed lying in bed receiving oxygen by nasal cannula (a device for delivering oxygen by way of two small tubes that are inserted into the nostrils). The oxygen concentrator (a device used to provide oxygen therapy) was set at 3.5 liters/minute. During an interview, on 10/24/16 at 8:55 a.m., licensed vocational nurse (LVN 2) stated that Resident 8 was receiving oxygen at 3.5 liters per minute. A review of Resident 8's Admission Record indicated Resident 8 was initially admitted to the facility on 7/20/16. Resident 8's diagnoses included chronic obstructive pulmonary disease ([COPD] a progressive disease that makes it hard to breath and less air flows in and out of the airways), heart failure, and anxiety. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W8LS11 Facility ID: CA940000079 If continuation sheet 27 of 38 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055170 (X3) DATE SURVEY COMPLETED 10/27/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PICO RIVERA HEALTHCARE CENTER 9140 Verner St Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 8's Minimum Data Set (MDS), a resident assessment and carescreening tool, dated 9/14/16, indicated Resident 8 was independent in cognitive skills (mental ability) for daily decision-making, requiring supervision while eating and extensive (weight bearing support) to total assistance from staff for other activities of daily living (ADLs) such as transfers and toilet use. A review of Resident 8's physician's orders, dated 7/20/16, indicated for staff to provide Resident 8 with oxygen at 2 liters per minute by nasal cannula. A review of Resident 8's untitled care plan, dated 8/18/16, indicated Resident 8 was at risk for respiratory distress and the staff's interventions were to give oxygen as ordered. b. On 10/24/16, at 9:09 a.m., during the initial tour of the facility, Resident 6 was observed lying in bed receiving oxygen by nasal cannula. The oxygen concentrator was set at 3.5 liters/minute and the normal saline humidifier was not labeled with date when it was first opened/used. During an interview, on 10/24/16, at 9:09 a.m., LVN 2 stated that Resident 6 was receiving oxygen at 3.5 liters per minute and the normal saline humidifier was not labeled. LVN 2 stated that staffs were required to label the normal saline humidifiers. A review of Resident 6's Admission Record indicated Resident 6 was initially admitted to the facility on 2/29/16, and was re-admitted to the facility on 7/19/16. Resident 6's diagnoses included dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W8LS11 Facility ID: CA940000079 If continuation sheet 28 of 38 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055170 (X3) DATE SURVEY COMPLETED 10/27/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PICO RIVERA HEALTHCARE CENTER 9140 Verner St Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and dysphagia (difficulty in swallowing). A review of Resident 6's MDS, dated 9/26/16, indicated Resident 6 had severe impairment in cognitive skills for daily decision-making and was totally dependent on staff for activities of daily living. On 10/24/16, at 9:20 a.m., LVN 2 reviewed Resident 8's and Resident 6's physicians' orders and stated that Resident 8 and Resident 6 should be receiving oxygen at 2 liters per minute and not 3.5 liters per minute. LVN 2 stated that Resident 6 did not have a current oxygen treatment care plan and that the licensed nurses should have created one. A review of the facility's undated policy titled, "Oxygen Administration," indicated for staff to administer oxygen per physician's orders and that oxygen equipment should be labeled.

F329 SS=D DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS CFR(s): 483.25(l)

F329 11/27/2016 Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Based on a comprehensive assessment of a resident, the facility must ensure that residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W8LS11 Facility ID: CA940000079 If continuation sheet 29 of 38 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055170 (X3) DATE SURVEY COMPLETED 10/27/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PICO RIVERA HEALTHCARE CENTER 9140 Verner St Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE clinical record; and residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure that gradual dose reduction (GDR) was attempted for one of seven residents (Resident 2), who were receiving psychotherapeutic drugs (medications that alter a person's mood or state of mind), in a total sample of 20 residents. This deficient practice had the potential to result in significant adverse consequences from possible excessive doses, inadequate indication for use, and prolonged use of psychotherapeutic medications. Findings: A review of Resident 2's Admission Record indicated Resident 2 was originally admitted to the facility on 1/17/14, and was readmitted on 4/25/16, with diagnoses that included essential hypertension (elevated blood pressure without a known cause), heart failure (condition when the heart is unable to pump sufficiently to maintain blood flow to meet the body's needs), and major depressive disorder (persistent feeling of sadness and loss of interest). A review of Resident 2's Minimum Data Set (MDS - a resident assessment and care planning tool, dated 8/13/16, indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W8LS11 Facility ID: CA940000079 If continuation sheet 30 of 38 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055170 (X3) DATE SURVEY COMPLETED 10/27/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PICO RIVERA HEALTHCARE CENTER 9140 Verner St Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 2's cognition (mental ability) was intact. Resident 2 required limited assistance (staff provided guided maneuvering of limbs or other non-weight bearing assistance) to extensive assistance (weight bearing support) with activities of daily living. A review of Resident 2's physician's order, dated 4/25/16, indicated Lexapro (antidepressant medication) tablet 5 milligrams (mg), give 1 tablet by mouth in the morning for depression manifested by verbalization of sadness. A review of the Medication Administration Record (MAR) for Resident 2 indicated the resident had been receiving Lexapro 5 mg 1 tablet by mouth every morning since it was ordered on 4/25/16. The MAR indicated Resident 2 was monitored for episodes of depression by verbalization of sadness every shift. The MAR indicated 0 (zero) verbalization of sadness for the whole month of October 2016. A review of Resident 2's care plan, dated 7/24/14, and revised on 9/24/14, indicated Resident 2 had episodes of depression manifested by verbalization of sadness. Care plan interventions included to administer antidepressant medications as per physician's order. Another intervention indicated gradual dose reduction review as indicated. A review of the facility's Psychotropic Summary Sheet did not indicate behavior data from the time period of April 2016 - September 2016. Resident 2 had 0 (zero) episodes of depression manifested by verbalization of sadness. On 10/25/16 at 1:45 pm, an interview was conducted with the facility's director of nursing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W8LS11 Facility ID: CA940000079 If continuation sheet 31 of 38 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055170 (X3) DATE SURVEY COMPLETED 10/27/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PICO RIVERA HEALTHCARE CENTER 9140 Verner St Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (DON). DON stated Resident 2 had been receiving Lexapro since 4/25/16. DON acknowledged that the facility failed to do a gradual dose reduction (GDR) of the antidepressant medication Lexapro for Resident 2. There was no documented behavior since April 2016. DON was unable to find documented evidence that a gradual dose reduction for Lexapro was attempted if the resident may benefit from it. There was no documented evidence of a resident-specific clinical rationale describing why a gradual dose reduction would be clinically contraindicated. On 10/25/16 at 3:10 pm, an interview with Resident 2 was conducted, with Spanish speaking surveyor as translator, and stated he liked living in the facility and the staff treated him well. Resident 2 stated that although he missed his deceased wife, he denied feeling hopeless or helpless. Resident 2 was observed smiling during the interview and he was pleasant and cooperative the entire conversation. A review of the facility's Activity Participation Report indicated Resident 2 had been attending independent activities provided by the facility for the months of August 2016, September 2016 and October 2016. On 10/26/16 at 1:15 pm, an interview was conducted with facility's activity director (AD), who stated Resident 2 was attending activities every day. AD stated Resident 2 liked to read newspaper in the morning, liked to sing, attended groups and interacted with others very well. A review of the facility's undated policy and procedure titled, "Psychotherapeutic Drug Overview" indicated the purpose of the policy is to promote GDR or discontinuation of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W8LS11 Facility ID: CA940000079 If continuation sheet 32 of 38 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055170 (X3) DATE SURVEY COMPLETED 10/27/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PICO RIVERA HEALTHCARE CENTER 9140 Verner St Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE psychotherapeutic medications. GDR as per

F329 is done twice in first year and once a year thereafter unless clinically contraindicated.

F431 SS=D DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS CFR(s): 483.60(b), (d), (e)

F431 11/27/2016 The facility must employ or obtain the services of a licensed pharmacist who establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W8LS11 Facility ID: CA940000079 If continuation sheet 33 of 38 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055170 (X3) DATE SURVEY COMPLETED 10/27/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PICO RIVERA HEALTHCARE CENTER 9140 Verner St Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the temperature of a refrigerator used to store medications was within 36-46 degrees Fahrenheit. One of two medication refrigerators had an improper temperature during a random inspection of the medication storage area. The temperature of the medication refrigerator in the West Station was not maintained within 3648 degrees Fahrenheit. This deficient practice may jeopardize the drug potency of the drugs stored in the refrigerator, resulting to ineffective medical treatment to the residents. Findings: During an inspection of the facility's West station medication area, on 10/25/16 at 10:15 a.m., the medication refrigerator that kept drugs such as Lorazepam (a medication used to treat anxiety), Pneumovax (a vaccine in liquid form), Epogen (a medication used to treat a low number of red blood cells), and Dronabinol (a medication used to treat nausea and vomiting), had a thermometer inside that read 28 degrees Fahrenheit. LVN 1 looked at the thermometer and confirmed that the reading was correct. LVN 1 stated that it was too cold and she would inform the maintenance supervisor. On 10/25/16 at 10:55 a.m., the maintenance supervisor installed another thermometer in the refrigerator together with the previous one to determine if the previous thermometer was defective. The maintenance supervisor left the thermometers in the refrigerator for five minutes. The reading of the previous FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W8LS11 Facility ID: CA940000079 If continuation sheet 34 of 38 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055170 (X3) DATE SURVEY COMPLETED 10/27/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PICO RIVERA HEALTHCARE CENTER 9140 Verner St Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE thermometer read 40 degrees Fahrenheit and the newly installed thermometer read 50 degrees Fahrenheit. During another inspection of the medication refrigerator at the West station of the facility on 10/25/16 at 3:07 p.m., the thermometer in the refrigerator read 26 degrees Fahrenheit. A review of the facility's medication temperature log for the month of September and October 2016 indicated that on 10/25/16, the staff recorded the refrigerator temperature at 30 degrees Fahrenheit. A review of the facility's policy and procedure titled, "Medication Refrigerator Temperature Log (36-46 Degrees Fahrenheit is required), indicated that the medication refrigerator temperature is to be checked and recorded daily. The temperature range should be within 36-46 degrees Fahrenheit.

F465 SS=E SAFE/FUNCTIONAL/SANITARY/COMFORTA F465 BLE ENVIRON CFR(s): 483.70(h) 11/27/2016 The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide a safe and functional environment for residents and staff by not ensuring the shower room in the West Station by Room 27 was in good condition and by not ensuring proper testing of the emergency generator. There were two round caps for the shower bars FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W8LS11 Facility ID: CA940000079 If continuation sheet 35 of 38 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055170 (X3) DATE SURVEY COMPLETED 10/27/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PICO RIVERA HEALTHCARE CENTER 9140 Verner St Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE inside the shower room observed to be loose, exposing sharp metal edges. This deficient practice had the potential to put the residents at risk for injury from the exposed metal edges. The facility's generator log indicated that the emergency generator was not tested under full load every 14 days for the months of May 2016 - October 2016. Findings: 1. On 10/25/16 at 1:30 pm, during an environmental inspection of the facility, two round caps for the shower bars inside the shower room in the West Station by Room 27 were observed loose exposing sharp metal edges. On 10/25/16 at 1:45 pm, an interview was conducted with the facility's maintenance supervisor who stated, the round caps cover the shower bar screws. Maintenance supervisor stated that the round caps were loose and have sharp metal edges that might cause accidents to residents. Maintenance supervisor stated he will place adhesive to make sure the caps were securely fastened to the wall to prevent exposing sharp edges. On 10/25/16 at 2:00 pm, an interview was conducted with the director of nursing (DON). DON confirmed that the round caps for the shower bars were loose and needed repair. A review of the facility's undated Interior and General Maintenance manual indicated check grab bars and all protective guards and devices in toilets, bathrooms and showers regularly. Repair immediately any loose bars or guards. 2. During the maintenance log review on 10/25/16 at 9:00 am, the evaluator noted that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W8LS11 Facility ID: CA940000079 If continuation sheet 36 of 38 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055170 (X3) DATE SURVEY COMPLETED 10/27/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PICO RIVERA HEALTHCARE CENTER 9140 Verner St Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the generator was tested weekly but was not tested under full load for 30mins for the months of May 2016-October2016. During an interview on 10/25/16 at 9:15 am, the facility ' s maintenance supervisor stated that he had been testing the emergency generator weekly on transfer switch and he thought he was doing it the right way. Maintenance supervisor also stated that he had been testing the generator every 14 days on full load in the past but he changed it to every week under transfer switch. He further stated he was testing the generator on full load only on a monthly basis. According to the California Code of regulations, Title 22, Licensing and Certification of Health Facilities, Section 72641 (e) indicated that emergency generator shall be tested at least every 14 days under full load condition, for a minimum of 30 minutes.

F468 SS=E CORRIDORS HAVE FIRMLY SECURED HANDRAILS CFR(s): 483.70(h)(3)

F468 11/27/2016 The facility must equip corridors with firmly secured handrails on each side. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide firmly secured handrail by the west nursing station that was not firmly affixed to the wall. This deficient practice had the potential to cause FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W8LS11 Facility ID: CA940000079 If continuation sheet 37 of 38 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055170 (X3) DATE SURVEY COMPLETED 10/27/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PICO RIVERA HEALTHCARE CENTER 9140 Verner St Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE accident and hazard to the residents. Findings: During the General Observation of the facility in the presence the director of nursing (DON) on 10/24/16 at 1:20 p.m., the evaluator noted that the wooden handrail by the west nursing station between rooms 23 and 24 was loose and unsecured to the wall. The metal support for the handrail was broken and exposed with sharp metal edges. There were two residents in their wheelchairs that could use the handrail as a means by which they could propel themselves. During an interview on 10/24/16 at 1:25pm, the DON confirmed that the wooden handrail was loose from the wall and the support-brace for the handrail was broken with exposed sharp metal edges. DON further stated the sharp edges and loose handrail were safety hazard and should be fixed right away by the maintenance department. On 10/24/16 at 1:35 pm, maintenance supervisor assessed the handrail by the west nursing station. Maintenance supervisor confirmed the handrail was loose and the support-brace for the handrail was broken with exposed sharp metal edges. Maintenance supervisor stated he would repair the handrail as soon as possible. A review of the facility ' s undated maintenance manual indicated that handrails are inspected to determine that they are firmly affixed to the wall, easy to grasp by residents and are free of sharp edges or splinters. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W8LS11 Facility ID: CA940000079 If continuation sheet 38 of 38