Other·June 14, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Amended 5/21/19 The following reflects the findings of the Department of Public Health during a Recertification survey and investigation of two Facility Reported Incidents (FRI). FRI number: CA00593642 FRI number: CA00602427 Representing the Department of Public Health: Surveyor ID: 36356, RN, HFEN Surveyor ID: 40821, RN, HFEN Surveyor ID: 40994, HFE, Pharmacist Consultant Total Census: 56 Sample Size: 14 Highest Severity and Scope: G There were no deficiencies issued as a result of FRI CA00593642. One deficiency (F 600) was issued as a result of FRI CA00602647.

F550 SS=D Resident Rights/Exercise of Rights CFR(s): 483.10(a)(1)(2)(b)(1)(2)

F550 05/29/2019 §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, 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: MYW111 Facility ID: CA970000052 If continuation sheet 1 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure one of 14 sampled residents (7), who was dependent on staff for eating, was treated with dignity and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 2 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 respect during meal. A restorative nursing assistant did not maintain an eye level, and was standing up, while assisting Resident 7 with the meal. This deficient practice placed Resident 7 at risk for not being honored, respected and treated with dignity, and had the potential to negatively affect the resident's self-esteem and self-worth by feeling rushed. Findings: A review of Resident 7's admission record indicated, the resident was admitted to the facility on 1/8/16 with diagnoses that included essential hypertension (high blood pressure with unknown secondary cause), hemiplegiaright dominant side (muscle weakness or partial paralysis on one side of the body [right]), and chronic obstructive pulmonary disease (lung disease that cause airflow blockage and breathing-related problems.) A review of Resident 7's Minimum Data Set (MDS), a standardized assessment and carescreening tool, dated 2/8/19 indicated Resident 7 had a Brief Interview for Mental Status[ (BIMS)-an assessment of cognition] score of 3, a severely impaired cognitive skills for daily decision making and was totally dependent on staff for bed mobility, transfers and eating. On 4/30/19 at 10:32 a.m. Resident 7 was observed in bed in Semi Fowlers position (resident positioned on their back with the head and trunk raised to between 15 to 45 degrees) eating meal, assisted by a restorative nursing assistant (RNA 1). RNA 1 was standing at the resident's bedside feeding the resident, while a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 3 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 chair was behind RNA 1. RNA 1 immediately sat down when he noticed that he was being observed. During an interview on 5/1/19 at 3:03 p.m., the director of staff development (DSD) stated, staff were instructed to feed the residents at eye level or sitting down to maintain dignity. DSD 1 also added, "so residents would not think they are a baby." During an interview on 5/2/19 at 7:43 a.m., the assistant director of staff development (ADSD) stated, when feeding the residents, staff had to make sure they were sitting down and not to rush the residents. A review of facility's policy and procedures titled, "Assistance with Meals" revised on 9/2013 indicated: residents requiring full assistance: residents, who can not feed themselves, will be fed with attention to safety, comfort and dignity, for example; not standing over resident while assisting with meals. A review of facility's admission packet Attachment F titled, "Resident Bill of Rights," dated 5/2011 indicated: the facility must care for its residents in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life.

F561 SS=D Self-Determination CFR(s): 483.10(f)(1)-(3)(8)

F561 06/29/2019 §483.10(f) Self-determination. The resident has the right to and the facility must promote and facilitate resident selfdetermination through support of resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 4 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 choice, including but not limited to the rights specified in paragraphs (f)(1) through (11) of this section. §483.10(f)(1) The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part. §483.10(f)(2) The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident. §483.10(f)(3) The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility. §483.10(f)(8) The resident has a right to participate in other activities, including social, religious, and community activities that do not interfere with the rights of other residents in the facility. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, facility failed to give one of 14 sampled residents (20) an opportunity to exercise the specific preferences regarding choosing a shower over a bed bath. Resident 20 wanted to have a shower, but staff did not honor the resident's preferences by providing bed bath instead, due to a contact isolation (used to prevent the spread of diseases that can be spread through contact) precaution status. This deficient practice potentially limited FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 5 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 20's autonomy in choosing a shower instead of bed bath, which could negatively affect resident's psychosocial well-being. Findings: A review of Resident 20's face sheet (admission record), indicated an admission date of 2/27/19 with diagnoses of essential hypertension (high blood pressure with unknown secondary cause), benign prostatic hyperplasia (prostate gland enlargement in men) and extended spectrum beta-lactamases urine ([ESBL] producing bacteria that can not be killed by many of the antibiotics that doctors used to treat infections discovered in urine). A review of Resident 20's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 3/819 indicated Resident 20 had a Brief Interview for Mental Status (BIMS-an assessment of cognition) score of 15 (a score of 13-15 indicated intact cognition). The MDS section for "Functional Status" (individual's ability to perform normal daily activities required to meet basic needs) indicated Resident 20 needed extensive assistance with bed mobility, transfers and was totally dependent on bathing. A review of Resident 20's medical records (health record) dated 4/30/19 indicated Resident 20 was re-admitted on 4/27/19 at 11:00 a.m. The records indicated a urinary results for culture and sensitivity (culture determines what organism causing an infection; sensitivity determines how the organism can best be treated) was received from acute hospital on 4/30/19. Resident 20 was then placed on contact isolation at 9:00 p.m. for ESBL in the urine and a course of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 6 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 intravenous antibiotic (liquid antibiotic delivers directly into a vein) was started. During an observation and interview on 5/1/19 at 11:32 a.m., Resident 20 was observed in bed since early morning. Certified Nursing Assistant (CNA 2) assigned to the resident stated Resident 20 was scheduled for shower on the same day, but she performed a bed bath instead. CNA 2 stated the reason was because Resident 20 was placed on contact isolation 5/1/19 and was not allowed to have a shower. During an interview on 5/1/19 1:08 p.m., Licensed Vocational Nurse (LVN 2) stated Resident 20 could not have a shower since he was on contact isolation, because to prevent the spread of infection as much as possible. LVN 2 further stated Resident 20 only had a bed bath, but the resident usually agreed, and would answer "yes" as long as the procedures was explained to him. During an interview on 5/01/19 2:53 p.m., Registered Nurse (RN 1) stated Resident 20 could not have a shower, only bed bath due to his contact isolation status. During an interview on 5/01/19 3:03 p.m., Director of Staff Development (DSD) stated Resident 20 or any other resident on an isolation precaution could have a bed bath or a shower. DSD stated, resident on isolation can have a shower as long as all other residents were done using the shower room. During an interview on 5/2/19 3:00 p.m., Resident 20 verbalized he needed and really wanted to have a shower. Resident 20 stated he would like to have a shower and have his fingernails trimmed. Resident 20 further stated he felt dirty and wanted a shower "today.' FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 7 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F600 Free from Abuse and Neglect CFR(s): 483.12(a)(1)

F600 SS=G PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 05/29/2019 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure one of 14 sampled residents (3), was free from physical abuse inflicted by a certified nursing assistant (CNA 1), who physically hit Resident 3 in the face. On 8/31/18, Resident 15 witnessed CNA 1 hit Resident 3 on the face. During further interviews, Resident 15 (Resident 3's roommate), 9, and 34, also complained about CNA 1. This deficient practice resulted in Resident 3 sustaining a bruise (discoloration of the skin) to the inner aspect of the left eye, and Resident 15, 9, and 35, verbalized CNA 1 was mean to them. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 8 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 Findings: On 4/30/19, during a Recertification survey, the facility reported incident (FRI) with allegation that on 8/31/18 that CNA 1 physically struck Resident 3 was investigated. On 4/30/19 at 8:50 a.m., Resident 3 was observed awake in bed, responding to questions but oriented to self only (able to state name). Resident 3 was observed to be hard of hearing and was unable to state if she was subject to any abuse. A review of Resident 3's admission record indicated the resident was admitted to the facility on 7/20/17, with diagnoses that included adult failure to thrive (a state of health decline including weight loss, decreased appetite, poor nutrition, and inactivity), dementia (a group of symptoms associated with a decline in memory or other thinking skills) and unspecified visual disturbance and unspecified hearing loss. A review of Resident 3's Minimum Data Set (MDS), a standardized assessment and carescreening tool, dated 4/29/19, indicated Resident 3 had severe cognitive impairment (ability to think, recall and understand) for daily decision making and required extensive assistance with personal hygiene and dressing. A review of Resident 3's History and Physical examination (H&P) completed by the attending physician (MD 1) on 7/28/18, indicated Resident 3 did not have the capacity to understand and make decisions. A review of an Incident Report dated 8/31/18 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 9 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 timed at 1:00 p.m., completed by Licensed Vocational Nurse (LVN 1), indicated Resident 3 was noted with a discoloration to the inner corner aspect of the left eye, which was purplish in color, that measured 1.5 centimeter (cm) by 1.4 cm. A review of a Bruise/ Skin Tear/ Abrasion Assessment form, dated 8/31/18 at 1:00 p.m., indicated Resident 3 had a discoloration to the corner of the left eye measuring 1.5 cm by 1.4 cm in width. A review of MD 1's order dated 8/31/19 at 5:33 p.m., indicated a STAT (urgent) x-ray (pictures of inside the body) of the left eye. The x-ray results dated 8/31/19 at 7:01 p.m. showed no broken bones. On 5/01/19 at 1:25 p.m., during an interview with Resident 3's roommate (Resident 15), the resident stated she remembered CNA 1, who no longer worked at the facility, treated Resident 3 "badly". A review of Resident 15's Admission Record indicated the resident was admitted to the facility on 2/13/12, and re-admitted on 1/1/19, with diagnoses that included aplastic anemia (low amount of red blood cells). A review of Resident 15's MDS, dated 3/1/19, indicated the resident had no cognitive impairment (ability to think, recall, understand and make daily decisions). Resident 15 was non English speaking and preferred to speak in her native language. On 5/01/19 at 1:35 p.m., during an interview with Resident 15, interpreted by the Director of Staff Development (DSD), the resident stated she witnessed CNA 1 hit Resident 3's face with both hands. Resident 15 demonstrated by FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 10 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 closing both fists and repeatedly moving both fists towards Resident 3's face. Resident 15 stated Resident 3 would constantly ask for assistance to go to the restroom at night, calling out every 5 to 10 minutes and "CNA 1 did not like that." On 5/01/19 at 2:07 p.m., during an interview with the director of nursing (DON), stated the alleged incident involving Resident 3 and CNA 1, happened on the 11 p.m. to 7 a.m. shift on 8/30/19. On 5/01/19 at 2:12 p.m., during a telephone interview with CNA 5, who was no longer working for the facility, stated on 8/31/18, she worked on the 7 a.m. to 3 p.m. shift. CNA 5 stated, while assisting Resident 3 with grooming, and personal hygiene, she noticed a bruise on the resident left eye area. CNA 5 stated when asked Resident 3 what happened, the resident told her somebody hit her on the face. CNA 5 stated Resident 3 could not identify the perpetrator because she was blind. CNA 5 stated, Resident 15 overheard the conversation between her and Resident 3, and identified CNA 1 as the staff who hit Resident 3. CNA 5 stated she reported the abuse allegation to licensed vocational nurse (LVN 1). During an interview with LVN 1 on 5/01/19 at 2:53 p.m., LVN 1 confirmed CNA 5 reported Resident 3's bruise, and abuse allegation. LVN 1 Resident 3's purple discoloration to the left eye measured about 1.5 cm. LVN 1 stated she asked Resident 3 what happened and whether she was hit by anybody, but Resident 3 did not provide an answer. LVN 1 stated she only interviewed Resident 3 and did not interview Resident 15 at that time. On 5/01/19 at 3:53 p.m., during an interview FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 11 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 with Resident 34, the resident stated CNA 1 worked during the night shift and was sometimes "mean". Resident 34 explained she got into verbal argument with CNA 1 once in the past (was unable to recall the date and time), because CNA 1 used a bad word, which caused Resident 34 to feel angry. A review of Resident 34's MDS, dated 3/27/19, indicated Resident 34 had no cognitive impairment (ability to think, recall, understand and make daily decisions). On 5/02/19 at 9:17 a.m., during an interview with Resident 9, she stated she knew CNA 1, who worked during the 11 p.m. to 7 a.m., shift. Resident 9 stated CNA 1 was mean and had a bad attitude when asked to assist with cleaning after a bowel movement. Resident 9 stated she reported Admissions Coordinator (AC) that she was uncomfortable with CNA 1's bad attitude. Resident 9 stated she did not report any neglect because she was scared of what CNA 1 would do to her in retaliation. A review of Resident 9's MDS, dated 2/17/19, indicated Resident 9 had no cognitive impairment (ability to think, recall, understand and make daily decisions). On 5/02/19 at 9:28 a.m., during an interview with AC, stated CNA 1 was reported to her for not answering the call lights on time, "or asking them what they wanted, to that effect" but did not recall any reports of attitude problems. The AC stated she would inform the DON of any reports from the residents. On 5/02/19 at 9:49 a.m., in the presence of the DON, an attempt to reach CNA 1 for an interview failed. On 5/02/19 at 10:09 a.m., during an interview FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 12 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 with the DON, stated LVN 1 made her aware of the abuse allegation on 8/31/18 and the DON reported to the Administrator. The DON stated CNA 1 was placed on suspension pending the investigation. The DON stated she had not received any reports regarding CNA 1 from AC. On 5/02/19 at 10:47 a.m., during an interview, the Administrator confirmed the DON notified him of the alleged abuse on 8/31/19 and the DSD was responsible for the investigation. On 5/02/19 at 11:18 a.m., during an interview, the DSD stated CNA 1 was placed on preventative suspension on 8/31/18. The DSD stated CNA 1 denied physical abuse towards Resident 3. A concurrent record review indicated CNA 1 addressed a resignation letter to the DSD dated 9/1/18. On 5/02/19 at 1:18 p.m., during an interview, the DSD stated he unsubstantiated the allegation of abuse between Resident 3 and CNA 1, because CNA 1 resigned, and DSD was unable to do a follow up interview with her. On 5/02/19 at 1:19 p.m., in the presence of the DON and ADM, a second telephone call to reach CNA 1 for interview failed. A review of a facility's policy titled "Abuse Program" last revised on 3/11/19 indicated the facility will identify and investigate all suspicions or allegation of abuse; reviewing the occurrence, patterns and trends that may constitute abuse. This information will be used to determine the direction of the investigation. A review of the facility's policy and procedure titled "Abuse Program," revised 3/11/9 indicated the facility was to maintain an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 13 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 environment free of abuse and neglect. The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. Residents will not be subjected to abuse by anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends or other individuals.

F656 SS=E Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 05/29/2019 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 14 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to create a comprehensive, and implement a care plan for two of 14 sampled residents (3, 35) by: a. Resident 3 did not have a comprehensive care plan to address behavioral needs related to bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). b. Resident 35 care plan was not implemented regarding behavioral needs related to schizophrenia (a mental disorder characterized by thoughts or experiences that seem out of touch with reality, disorganized speech or behavior, and decreased participation in daily activities). The deficient practices of failing to create and implement a comprehensive care plan in order to manage behavioral needs increased the risk that Residents 3 and 35 would be provided FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 15 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 care that was not resident-centered or appropriate for their conditions, decreasing their ability to achieve and maintain their highest level of physical, mental, and psychosocial well-being. Findings: a. On 05/01/19 at 10:27 AM, during a record review, Resident 3's clinical record indicated admitted to the facility on 7/20/17 with diagnoses including, but not limited to: dementia (a group of thinking and social symptoms that interferes with daily functioning.), psychosis (a mental disorder characterized by a disconnection from reality), major depressive disorder ([MDD] a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and bipolar disorder. A review of Resident 3's physician order dated 2/11/19 indicated that she was prescribed quetiapine (a medication used to treat mental illness) 50 milligrams (mg) at bedtime for "bipolar disorder." A review of Resident 3's Psychotropic Summary Sheets indicated that she was prescribed the quetiapine to control "bipolar disorder manifested by delusional thinking that people are trying to hurt her" and also "psychosis manifested by screaming and yelling." A review of Resident 3's clinical record did not contain a care plan specific to bipolar disorder FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 16 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 or for a behavior of "delusional thinking that people are trying to hurt her." During further review of Resident 3's available care plans dated 7/9/18 indicated that the only behaviors which had care plans were "selfisolation" due to MDD and "screaming and yelling" for anxiety disorder, but not psychosis. On 05/02/19 at 12:00 p.m., during an interview, the director of nursing (DON) stated the diagnosis/behaviors for the use of quetiapine were not specific and not clear. The DON confirmed Resident 3 did not have a care plan specific to bipolar disorder or for a behavior of "delusional thinking that people are trying to hurt her." The DON also stated that "screaming and yelling" was listed under the anxiety care plan probably because the person who made the care plan did it incorrectly. The DON stated that care plans available are not adequate to address the resident's needs. b. On 05/01/19 at 12:56 p.m., during a record review, Resident 35's clinical record indicated admitted to the facility on 3/19/19 with diagnoses including, but not limited to: schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly.) A review of Resident 35's physician order dated 3/19/19 indicated she was prescribed clonazepam (a medication used to treat anxiety disorder) 1 mg at bedtime for "schizophrenia manifested by agitation." During a review of Resident 35's physician orders indicated the physician had not written any orders to monitor the behaviors of "agitation" or for side effects (unwanted secondary effects of taking medications) of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 17 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 clonazepam. A review of Resident 35's behavioral care plan for schizophrenia dated 3/20/19 indicated one of the resident's goals of therapy was "will have 0-1 episodes of agitation daily for three months." The interventions listed in the care plan included: "evaluate the effectiveness and side effects of mediations for possible decrease/elimination ... [of the clonazepam]" and "monitor for side effects and report to medical doctor (MD) promptly." During further review of Resident 35's clinical record, including the medication administration record ([MAR] a record used to document medications given and behaviors and side effects observed) indicated the facility staff were not documenting episodes of "agitation" or the side effects of clonazepam. On 05/01/19 at 1:30 p.m., during an interview, the DON confirmed there were no physician order to monitor for behavioral episodes of "agitation" or the side effects of clonazepam. On 05/02/19 at 12:00 p.m., during an interview, the DON stated she had made a request for the Resident 35's physician to add an order directing nursing staff to monitor for side effects of clonazepam and manifestations of the behavior of "agitation." The DON confirmed those items were not being monitored up to now. The DON stated that because of the lack of monitoring, the facility was not implementing Resident 35's behavioral care plan as written. A review of the facility's undated policy titled "Care Planning - Interdisciplinary Team" indicated"Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 18 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F657 Care Plan Timing and Revision CFR(s): 483.21(b)(2)(i)-(iii)

F657 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 05/29/2019 §483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must be(i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-(A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to update the care plan of one of 14 sampled residents (3) when behavioral data indicated the care plan's interventions were not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 19 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 meeting the resident's clinical goals. The deficient practice of failing to revise the behavioral care plan to manage behavioral needs increased the risk Resident 3 not being provided with care that was resident-centered, which could decrease the resident's ability to achieve, maintain highest level of physical, mental, and psychosocial well-being. Findings: On 05/01/19 at 10:27 a.m., during a record review, Resident 3's clinical record indicated admitted to the facility on 7/20/17 with diagnoses including, but not limited to: dementia (a group of thinking and social symptoms that interferes with daily functioning.), psychosis (a mental disorder characterized by a disconnection from reality), major depressive disorder ([MDD] a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). A review of Resident 3's care plan for anxiety disorder dated 7/9/18 indicated she was to be monitored for the behavior of "screaming and yelling" as evidence by exhibiting episodes of anxiety. The care plan also indicated the clinical goal for the interventions to treat anxiety disorder was for the resident to " ...have 0-1 episodes of being anxious daily x 3 months ..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 20 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 the behavior data on the Psychotropic Summary Sheet indicated the facility was actually monitoring the behavior of "inability to relax" rather than "screaming and yelling" as evidence by Resident 3 being anxious. A review of November 2018 to present, the behavior data indicated the resident was having multiple episodes of behaviors attributed to anxiety that exceeded the care plan goal (87 episodes in November 2018, 62 in December 2018, 70 in January 2019, 64 in February 2019, and 56 in March 2019). A review of the Interdisciplinary Team ([IDT] a group of individuals from different medical backgrounds tasked with creating and revising plans of care for residents living in skilled nursing facilities) notes on the Interdisciplinary Team Conference Summary/Behavior Management form indicated IDT reviewed Resident 3's behavioral management care plan on the following dates: 6/29/18, 7/20/18, 10/12/18, 12/3/18, 1/4/19, 2/4/19, 3/4/19, and 4/4/19. On each of those dates the IDT note indicated the behavior related to anxiety was "inability to relax." The IDT made the same recommendation of "IDT recommends no changes at this time because resident needs continuity or care and treatment" on each of those dates. There was no other evidence or documentation within Resident 3's clinical record to indicate the behavioral management care plan had been revised at any time since its initial creation. On 05/02/19 at 12:00 p.m., during an interview, the director of nursing (DON) stated when the IDT meet to review the behavioral management care plan, it only "sometimes" has the resident's behavioral data available. The DON stated the IDT meetings usually do not involve the licensed vocational nurses (LVN's) or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 21 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 certified nursing assistants (CNAs) or other staff who provide direct care to the resident, who observe or document behaviors. The DON stated "inability to relax" was also not specific enough for direct care staff to really know what or how to document behaviors consistently. The DON also stated she agreed the behavioral management care plan for anxiety had not been updated or revised, but needed to be. The DON stated, given the behavioral data, the care plan interventions for "restlessness" and "inability to relax" do not seem to be effective as the number of behavioral episodes far exceeded Resident 3's care plan's clinical goals. The DON stated "screaming and yelling" was listed as a behavior to monitor under the anxiety care plan rather than "inability to relax" most likely because the person who made the care plan did it incorrectly. The DON stated the behavioral management care plan for anxiety was not adequate to address Resident 3's needs as it had not been revised or updated given the behavioral data. According to the facility's undated policy titled "Care Planning - Interdisciplinary Team" indicated that "The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team which includes, but is not necessarily limited to the following personnel: i. The Charge Nurse responsible for resident care, j. Nursing Assistants responsible for the resident's care ..."

F675 SS=D Quality of Life CFR(s): 483.24

F675 05/29/2019 § 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 22 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, facility failed to maximize one of 14 sampled residents (17) eating abilities, when not assisting the resident was in proper position during mealtime. This deficient practice potentially could negatively affect Resident 17's access to food, leading to decreased meal intake, and weight loss. Findings: A review of Resident 17's face sheet (admission record), indicated an admission date of 5/24/18 with diagnoses of type 2 diabetes mellitus (abnormal blood sugar levels), essential hypertension (high blood pressure), and iron deficiency anemia (insufficient iron in the body). A review of Resident 17's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 3/819 indicated the resident had a Brief Interview for Mental Status (BIMS-an assessment of cognition) score of 7 (a score of 0-7 indicates severe impairment of cognition). A concurrent review of Resident 17's MDS section "Functional Status" (individual's ability to perform normal daily FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 23 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 activities required to meet basic needs) indicated the resident needed extensive assistance with bed mobility, totally dependent on transfers and needed supervision, and cueing when eating. A review of Resident 17's "Order Summary Report" dated 5/2/19, indicated the resident's primary physician ordered Megace (appetite stimulant) daily. The order indicated to monitor for loss of appetite, and behavior of poor oral intake due to the Duloxetine medication (medication to treat depression). During an observation on 5/1/19 at 7:18 a.m., Resident 17 was lying on his bed in low semi fowler's position (positioned on back with the head and trunk raised to between 15 to 45 degrees), over bed table in front of him with 15% of food left on his food plate. Resident 17 stated, he was tired and did not want to eat anymore. During an observation, and interview on 5/2/19 at 8:24 a.m., Resident 17 was observed eating by himself. The resident was lying on his bed, in a low semi flowers position. Resident 17's body was not in correct alignment, and the over bed table with food plate that was in front of him was not at the level of his face. Resident 17 was low in bed and the elbow was high up, and bent. Certified Nursing Assistant (CNA 4) asked Resident 17 if he wanted to be pulled up since he was very low. Resident 17 was still sliding down and appeared to have difficulty accessing the food. During observation, Resident 17 replied to CNA 4 "I don't care," and even though the resident was having difficulty accessing the food, CNA 4 left the resident's room right away. A review of Resident 17's care plan dated 5/25/19, indicated the resident was at risk for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 24 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 dehydration with an intervention to assist at mealtime, and to offer all food or fluid. Resident 17's care plan indicated a potential for weight changes with interventions to monitor at meal times to assess eating patterns.

F693 SS=D Tube Feeding Mgmt/Restore Eating Skills CFR(s): 483.25(g)(4)(5)

F693 05/29/2019 §483.25(g)(4)-(5) Enteral Nutrition (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident§483.25(g)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and §483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure one of two sampled residents (42), who had a gastronomy tube feeding ([G-tube] a tube inserted through the abdomen that delivers nutrition directly to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 25 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 stomach, as an intervention to maintain nutritional status where the mouth is inadequate, unsafe or inaccessible), was provided the prescribed amount of G-tube feeding per the physician order. This deficient practice had the potential for Resident 42 not to meet the required nutritional needs, and had the potential for weight loss. Findings: During an initial tour of the facility on 4/30/19 at 9:18 a.m., Resident 42 was observed lying in bed with a G-tube feeding of Glucerna 1.2 carbsteady liquid feeding bottle dated 4/29/19 at 10:30 p.m. Resident 42's G-tube feeding rate was at 45 milliliters per hour (ml/hr). There was 1,300 ml of liquid left in the feeding bottle (total amount was 1,500 ml) and the infusion pump (a medical device that delivers fluids, such as nutrients and medications, in controlled amounts) was turned off. A review of Resident 42's admission record (Facesheet) dated 5/2/19 indicated the resident was admitted to the facility on 10/17/13 and readmitted on 10/13/16 with diagnoses that included epileptic seizures (a central nervous system disorder in which brain activity becomes abnormal, causing seizures or periods of unusual behavior, sensations, and sometimes loss of awareness), cerebral infarction (blockage or narrowing in the arteries supplying blood and oxygen to the brain), dysphagia (difficulty swallowing) with use of Gtube. A review of Resident 42's History and Physical form dated 11/29/18 indicated the resident did not have the capacity to understand and make FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 26 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 decisions. A review of Resident 42's physician order dated 2/12/18 indicated an order for Glucerna 1.2 formula at 45 cubic centimeter/ hour (cc/hr = ml/hr) for 20 hours, to provide 900 cc or 1080 kilocalorie (kcal) in 24 hours via an enteral pump, on at 12 p.m. and off at 8 a.m. During an observation and interview with Licensed Vocational nurse (LVN 1) on 5/01/19 at 11:12 a.m., Resident 42's G-tube feeding bottle was observed dated 4/29/19 at 10:30 p.m. at a rate of 45 ml/hr. The infusion pump indicated 865 mls total was infused. LVN 1 stated Resident 42's G-tube feeding order was to infuse 45 ml/hr for 20 hours, with the infusion pump to be turned off at 8 a.m. and turned on at 12 p.m. LVN 1 stated the G-tube pump was also turned off during provision of care. LVN 1 stated Resident 42 "did not get a shower today". The calculations for the required amount of fluid as prescribed for Resident 42 were as followed: 1. The new feeding tube bottle started on 4/29/19 at 10:30 p.m. up to 4/30/19 at 8 a.m. equaled 9.5 hours at the rate of 45 ml/hr total required amount was 427.5 mls 2. The infusion pump was scheduled to be turned off on 4/30/19 from 8 a.m. to 12 p.m. 3. The infusion pump was scheduled to be turned on at 12 p.m. on 4/30/19. 4. From 4/30/19 at 12 p.m. to 5/1/19 at 8 a.m., equals 20 hours of infusion at the rate of 45 ml/hr, total required amount was 900 mls. However, the total required feeding amount between 4/30/19 at 10:30 p.m. to 5/1/19 at 8 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 27 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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.m. was 1,327.5 mls, compared to the observed infusion pump total amount of 865 mls. A concurrent review of Resident 42's weight record with LVN 1, indicated the resident weighed were as followed: 3/19/19 170 pounds (lbs), 4/19/19 168 lbs. The record did not show Resident 42's current weight for the month of May 2019. During an observation with Restorative Nurse Assistant (RNA 2) on 5/01/19 at 11:47 a.m., Resident 42 was observed on a transfer sling (used for transfers when a person requires 90100% assistance to get into and out of bed, with a pad that fits under the person's body in the bed and connects with chains to the lift frame, and a hydraulic pump is used to lift the person off the bed surface) that had a weight scale attached to it. RNA 2 stated Resident 42's weight scale read 169 lbs, but had to subtract 2 lbs for the weight of the sling, making the resident's weight 167 lbs. On 5/2/19 at 8:58 a.m., Resident 42's G-tube feeding bottle was observed dated on 5/1/19 at 12 p.m. at the rate of 45 ml/hr. The infusion pump was observed turned on and it indicated 572 mls total amount infused. During observation in the presence of LVN 1, the LVN 1 stated she hung the new bottle the previous day 5/1/19 at 12 p.m. LVN 1 stated it was 21 hours from the time she hung the new G-tube bottle. However, 21 hours multiplied by the rate of 45 ml/hr, revealed total required was 945 mls compared to the 572 mls infused. On 5/2/19 at 11:45 a.m. during an observation and interview with Registered Nurse(RN 1), for Resident 42's G-tube feeding was dated 5/1/19 at 12 p.m.. The infusion pump indicated a total amount infused of 593 mls. RN 1 stated the GFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 28 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 tube feeding should have completed the required 24-hours. LVN 1 stated the prescribed order was 900 ml total G-tube feeding in 24 hours. During an interview with the Director of Nursing (DON) on 5/02/19 at 3:11 p.m., stated the tube feeding was based on an assessed caloric intake needs and it was calculated per day. The DON stated the potential negative outcomes for not receiving the required amount of G-tube feeding included weakness, changes in skin integrity, a possible change in condition, weight loss, and abnormal laboratory values. A review of an undated facility's policy titled "Enteral Tube Feeding via Continuous Pump" indicated the purpose was to provide the nourishment to the resident who is unable to obtain nourishment orally (by mouth). A review of an undated facility's policy titled "Nutrition (Impaired)/ Unplanned Weight Loss Clinical protocol" indicated under the treatment and management section, the physician will authorize and the staff will implement appropriate general or cause-specific interventions with careful considerations to the following including: Nutritional needs, Hydration needs and Feeding tubes.

F711 SS=D Physician Visits - Review Care/Notes/Order CFR(s): 483.30(b)(1)-(3)

F711 05/29/2019 §483.30(b) Physician Visits The physician must§483.30(b)(1) Review the resident's total program of care, including medications and treatments, at each visit required by paragraph FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 29 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 (c) of this section; §483.30(b)(2) Write, sign, and date progress notes at each visit; and §483.30(b)(3) Sign and date all orders with the exception of influenza and pneumococcal vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure the attending physician signed and dated all orders during each visit for one of 14 sampled residents (35). The deficient practice of failing to ensure the attending physician signed, and dated the most recent orders during each visit, increased the risk of Resident 35 receiving suboptimal care based on orders that were not up-to-date resulting in a negative impact to the health, and well-being. Findings: On 05/01/19 at 12:56 p.m., during a record review, Resident 35's clinical record indicated admitted to the facility on 3/19/19 with diagnoses including, but not limited to: schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A review of the Order Summary Report indicated Resident 35's attending physician had not signed or dated the physician orders for March 2019, and April 2019. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 30 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 On 05/02/19 at 08:40 a.m., during an interview the director of nursing (DON) confirmed Resident 35's Order Summary Reports from March and April 2019 had not been signed by the physician. The DON stated she did not know when the orders were supposed to be signed by the physicians. On 05/02/19 at 08:45 a.m., during an interview, the medical records supervisor (MR) stated did not know why Resident 35's Order Summary Reports for March 2019, and April 2019 were not signed. The MR stated she was unclear about the time frame for the physicians to sign the Order Summary Reports. According to the facility's undated policy titled "Physician Services" indicated that "Physician orders and progress notes shall be maintained in accordance with current OBRA [Omnibus Budget Reconciliation Act] regulations and facility policy."

F756 SS=E Drug Regimen Review, Report Irregular, Act On CFR(s): 483.45(c)(1)(2)(4)(5)

F756 05/29/2019 §483.45(c) Drug Regimen Review. §483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. §483.45(c)(2) This review must include a review of the resident's medical chart. §483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 31 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. §483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure the attending physician responded to recommendations from the consultant pharmacist (PC) regarding medication therapy irregularities (use of medications that is inconsistent with accepted standards of practice for providing pharmaceutical services, not supported by medical evidence and/or that impedes or interferes with achieving the intended outcomes of pharmaceutical services) for three of 14 sampled residents (3, 17, 35). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 32 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 deficient practice of failing to ensure the attending physician responded to medication irregularities identified by PC increased the risk Residents 3, 17, and 35 could received medication therapy that was not optimal for their medical conditions or that did not meet the standard of care resulting in a potential negative impact to their health, and well-being. Findings: a. On 05/01/19 at 10:27 a.m., during a record review, Resident 3's clinical record indicated that she was admitted to the facility on 7/20/17 with diagnoses including, but not limited to: dementia (a group of thinking and social symptoms that interferes with daily functioning.), psychosis (a mental disorder characterized by a disconnection from reality), major depressive disorder ([MDD] a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). A review of Resident 3's physician order dated 2/11/19 indicated a prescribed quetiapine (a medication used to treat mental illness) 50 milligrams (mg) at bedtime for bipolar disorder. A review of the Psychotropic Summary Sheets indicated the facility was monitoring Resident 3 for two different behaviors related to the use of quetiapine: "bipolar disorder manifested by FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 33 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 delusional thinking that people are trying to hurt her" and "psychosis manifested by screaming and yelling." A review of the PC's consultation notes indicated on 2/5/19 the PC made a specific recommendation to the attending physician to clarify the use of quetiapine, and to provide additional information to ensure it was being used properly to manage Resident 3's behaviors. A review of PC notes specifically asked the attending physician to provide documentation that Resident 3's behaviors were "not due to psychological stressors or anxiety/fear stemming from misunderstanding related to the cognitive impairment that can be expected to improve/resolve as the situation is addressed." The PC notes indicated for the physician to clarify as to whether "screaming and yelling" was a continuous, disruptive behavior related to mania or psychosis, a behavior that presented a danger to Resident 3 or others, and was significant enough to cause a decline in function or prevent her from receiving needed care. However, the section of the PC's note titled "follow-through" was blank. During a review of Resident 3's clinical record found that it did not contain any documentation of a specific or direct response from the attending physician to the PC's recommendations to clarify the use of quetiapine, or to ensure the behaviors were disruptive enough to require management with quetiapine. A review of the Psychiatry Progress Notes dated 3/22/19 and 4/27/19 both indicated the behaviors exhibited by Resident 3 were not "major behavior disturbances, severe agitation, or violent behavior ..." and indicated Resident 3 was taking only 25 mg of quetiapine, however, the resident had been taking 50 mg since FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 34 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 2/11/19. The psychiatry notes both indicated the recommendation was to continue the medications as written as they were needed for continued symptoms and behavior management and that "reduction will worsen patient's mental condition. Clearly benefits outweigh risks." The Psychiatry Progress Notes from 3/22/19 and 4/27/19 did not indicate the psychiatrist had attempted to respond specifically to PC's request for clarification of the use of Resident 3's quetiapine. b. On 05/01/19 at 02:16 p.m., during a record review, Resident 17's clinical record indicated that he was admitted to the facility on 5/24/18 with diagnoses including, but not limited to: major depressive disorder ([MDD] a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A review of Resident 17's physician order dated 2/4/19 indicated he was prescribed duloxetine (a medication used to treat MDD) 20 mg once daily for depression manifested by "loss of appetite." A review of Resident 17's physician order indicated the resident had been taking duloxetine 20 mg continuously since 6/26/18. A review of the PC's consultation note dated 10/9/18 indicated the PC made a recommendation to the attending physician to perform a gradual dose reduction ([GDR] an attempt to reduce the dose of a medication in order to find the lowest effective dose or to discontinue the medication) for duloxetine or to provide clinical rationale as to why the attempt would be contraindicated (likely to cause harm). However, the section of the PC's note for "physician/prescribe response" was blank. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 35 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 During a review of the clinical records it contained no evidence the attending physician ever considered the PC's recommendation to perform a GDR on Resident 17's duloxetine medication. Resident 17's clinical record also indicated the dose of duloxetine had not been reduced since it was initiated on 6/26/18 and contained no documentation as to why an attempt to reduce the dose was contraindicated. c. On 05/01/19 at 12:56 p.m., during a record review, Resident 35's clinical record indicated that she was admitted to the facility on 3/19/19 with diagnoses including, but not limited to: schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A review of Resident 35's physician order dated 3/19/19 indicated she was prescribed clonazepam (a medication used to treat mental illness) 1 mg at bedtime for "schizophrenia manifested by agitation." A review of the PC's consultation note dated 4/15/19 indicated the PC requested the attending physician to provide clinical rationale regarding the choice of clonazepam to treat schizophrenia as clonazepam was not typically a medication used to treat schizophrenia. The PC also requested the attending physician to provide clarity on the behavior of "agitation" as it was a "vague" indication for a manifestation of behavior related to schizophrenia. However, the section of the PC's note titled "FollowThrough" was blank. During a review of Resident 35's clinical record indicated she had not been evaluated by a psychiatrist since the admission to the facility. There was no other documentation regarding the clinical rationale to continue the use of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 36 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 clonazepam or what behaviors constituted "agitation" was found. On 05/01/19 at 02:16 p.m., during an interview, the director of nursing (DON) was requested to provide all of the PC's consultation notes regarding Resident 3, 17, and 35's medication regimens. On 05/02/19 at 08:34 a.m., during an interview, the DON stated the three PC notes referenced above were all of the available PC notes available for Residents 3, 17, and 35. On 05/02/19 at 11:06 a.m., during a telephone interview, the PC stated he visited the facility around once per month to review the resident's medication regimens and write his recommendations to the attending physicians. The PC stated he had consulted for this facility for several years. The PC stated he had not personally received nor knew of any specific response from the attending physicians regarding the notes referenced for Residents 3, 17, or 35. On 05/02/19 at 12:00 p.m., during an interview, the DON stated she could not confirm or deny the PC's recommendations ever received a response from the attending physicians and she "doesn't know" whether the attending physicians ever responded specifically to the PC recommendations for Residents 3, 17, and 35. The DON stated she would work with medical records to try to locate any specific response to the PC's recommendations. On 05/02/19 at 02:04 p.m., the DON stated she was still looking to provide evidence or documentation of any specific response by the attending physician to the PC's recommendations referenced above for Residents 3, 17, and 35. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 37 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 On 05/02/19 at 03:51 p.m., at the time of the survey team's exit from the facility, the DON had still not provided any evidence that the attending physicians ever documented any response to the PC's recommendations for Resident 3, 17, or 35. According to the facility's policy titled "Medication Regimen Reviews" revised April 2007 indicated that "Copies of drug/medication regimen review reports, including physician responses, will be maintained as part of the permanent medical record." A review of an undated facility's policy titled "Physician Services" indicated that "The attending physician will determine the relevance of any recommended interventions from any discipline. The physician is not obligated to accept these recommendations if he or she has a clinically valid reasons for not doing so."

F758 SS=E Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) 05/29/2019 §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 38 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 §483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure four of 5 sampled residents (3, 17, 35, 107), psychotropic medications (any medication that affects brain activities associated with mental FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 39 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 processes and behaviors) drug/medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being by: a. Ensuring that psychotropic medications were used to treat only specific conditions as diagnosed and documented in the clinical record for Resident 3, 17, 35. b. Ensuring as needed ([PRN] not given on a scheduled basis) orders for psychotropic medications were limited to only 14 days for Residents 107. c. Ensuring a gradual dose reduction ([GDR] an attempt to reduce the dose of a medication in order to find the lowest effective dose or to discontinue the medication) for psychotropic medications was either attempted or documented with appropriate clinical rationale for Resident 17. d. Ensuring proper monitoring was done for adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) of psychotropic medications for Resident 35. These deficient practices of failing to ensure Residents 3, 17, 35, and 107 did not receive unnecessary medication therapy had the potential to negatively impact their health, and well-being by causing medication-related adverse effects including, but not limited to: drowsiness, dizziness, constipation, involuntary movements, and death. Findings: a. On 05/01/19 at 10:27 a.m., during a record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 40 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 review, Resident 3's clinical record indicated that she was admitted to the facility on 7/20/17 with diagnoses including, but not limited to: dementia (a group of thinking and social symptoms that interferes with daily functioning.), psychosis (a mental disorder characterized by a disconnection from reality), major depressive disorder ([MDD] a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). A review of Resident 3's physician order dated 2/11/19 indicated she was prescribed quetiapine (a medication used to treat mental illness) 50 milligrams (mg) at bedtime for bipolar disorder. During further review of the physician's orders indicated Resident 3 had been taking quetiapine 25 mg since 1/13/19 when it was initially recommended by the psychiatrist and the dose was later increased to 50 mg on 2/11/19 due to quetiapine being "ineffective." A review of the Psychotropic Summary Sheets indicated the facility was monitoring Resident 3 for two different behaviors related to the use of quetiapine: "bipolar disorder manifested by delusional thinking that people are trying to hurt her" and "psychosis manifested by screaming and yelling." A review of the Psychiatry Progress Notes dated 1/13/19 described Resident 3's behavior as "major behavior disturbance, severe agitation, or violent behavior which is unable to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 41 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 be redirected or manageable with the current medication regimen" and added a diagnosis of "bipolar disorder, unspecified." The previous Psychiatry Progress Notes dated 10/28/18, 11/24/18, and 12/23/18 made no mention of "bipolar disorder" or "psychosis" in the list of diagnoses. The Psychiatry Progress Notes from 1/13/19, 3/22/19, and 4/27/19 also made no mention of "psychosis." A review of the available Psychiatry Progress Notes 10/28/18, 11/24/18, and 12/23/18, did not make any detailed description of Resident 3's behaviors or how they were related to the psychiatric diagnoses listed. The notes also did not contain any clinical rationale or specific information used to arrive at the diagnoses, including bipolar disorder, or any evidence that all other potential causes for the behaviors (such as other medical conditions, psychological stressors due to misunderstandings related to dementia) had been evaluated, and ruled out before psychotropic medications were prescribed to control the behaviors. During a review of Psychiatric Progress Notes from 3/22/19 and 4/27/19 indicated Resident 3 was taking only 25 mg of quetiapine, however, the resident had been taking 50 mg since the order from 2/11/19. The next available Psychiatric Progress Note from 3/22/19 provided no information as to why the dose of quetiapine had been increased. The notes only contained a blanket statement reading: "Current medications need to be continued for symptoms and behavior management. Reduction will worsen patient's mental condition. Clearly benefits outweigh risks." A review of Resident 3's clinical record contained no further clinical insight into the rationale for the use of quetiapine. During observation of Resident 3 on the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 42 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 following days revealed: On 05/01/19 at 10:44 AM, Resident 3 was observed to be asleep in her room lying in her bed. On 05/01/19 at 04:45 PM, Resident 3 was observed to be asleep in her room lying in her bed. On 05/02/19 at 08:37 AM, Resident 3 was observed to be asleep in her room lying in her bed. On 05/02/19 at 12:00 p.m., during an interview, the director of nursing stated she agreed Resident 3's diagnosis and behaviors for the use of quetiapine were not specific, and not clear. b. On 05/01/19 at 2:16 p.m., during a record review, Resident 17's clinical record indicated he was admitted to the facility on 5/24/18 with diagnoses including, but not limited to: major depressive disorder ([MDD] a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A review of Resident 17's physician order dated 2/4/19 indicated he was prescribed duloxetine (a medication used to treat MDD) 20 mg once daily for depression manifested by "loss of appetite." A review of Resident 17's physician order indicated he had been taking duloxetine 20 mg continuously since 6/26/18. Another physician order dated 2/4/19 indicated the facility staff were to monitor Resident 17's "poor PO (by mouth) intake," three times daily, and document the percentage of each meal eaten. A review of Resident 17's physician order dated 3/28/19 indicated he was prescribed megesterol acetate (a medication used to increase appetite) 400 mg once daily for "appetite stimulant." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 43 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 However, Resident 17's clinical record indicated the dose of duloxetine 20 mg had not been reduced since it was initiated on 6/26/18. There was no documentation as to why an attempt to reduce the dose would be contraindicated (likely to cause harm). A review of Resident 17's Psychotropic Summary Sheet indicated he was being monitored for "depression manifested by loss of appetite" and in March of 2019, the resident only had two documented episodes of "loss of appetite." A review of Resident 17's medication administration record ([MAR] a record of behavioral monitoring and medications given to the resident) indicated that on most days during March 2019, the resident consumed 75 percent (%) or more of each meal. The Psychiatric Evaluation dated 3/22/19 confirmed a diagnosis of MDD, but indicated Resident 17 was not using any psychotropic medications and made no mention of the resident's duloxetine. The treatment plan indicated the psychiatrist recommended supportive therapy and behavioral intervention. A review of the Psychiatry Progress Notes dated 4/27/19 also indicated Resident 17 was not currently taking any psychotropic medication, even though the resident was taking duloxetine 20 mg daily for nearly 11 months. The treatment plan indicated the psychiatrist recommended to continue with supportive non-pharmacological therapy and "no psychotropic medication is recommended at this time." On 05/01/19 at 7:18 a.m., Resident 17 was observed lying on his bed with a bedside table FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 44 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 over him. The bedside table contained his breakfast plate with approximately 15% of breakfast still left on it. On 05/01/19 at 2:59 p.m., during an interview, the DON confirmed the two psychiatric notes dated 3/22/19 and 4/27/19 were the only notes available in Resident 17's clinical records. DON stated she will look for earlier psychiatric notes to discover why he was prescribed duloxetine but as of now she was not sure. The DON acknowledged Resident 17 had an oral hygiene issue which could also affect his ability or desire to eat. When asked specifically how they ruled out all other causes of "poor appetite" or "poor PO intake" before duloxetine was prescribed, the DON replied "I don't know." On 05/02/19 at 08:24 a.m., during an interview, the dietary supervisor (DS) stated Resident 17 was prescribed megesterol acetate in order to help increase his appetite. DS also stated that Resident 17 was very picky about the food and refuses a lot of meals. A review of the facility's drug reference manual titled "Mosby's 2019 Nursing Drug Reference" indicated that among the possible side effects for duloxetine are "decreased appetite" and "decreased weight." On 05/02/19 at 12:00 p.m., during an interview, the DON stated the facility defined "poor PO intake" as consuming 50% or less of meals. The DON acknowledged Resident 17's duloxetine may cause adverse effects including weight loss and decreased appetite according to the facility's drug reference. The DON stated she had not considered this as a possible explanation for Resident 17's weight loss or poor appetite. The DON stated she was not aware of any attempt to perform a GDR on duloxetine, confirmed the psychiatrist's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 45 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 recommendation was for Resident 17 to not use any psychotropic medication, and that given the potential adverse effects, duloxetine could possibly contribute to the behaviors of "poor appetite" and "poor PO intake" that it was prescribed to help treat. c. On 05/01/19 at 12:56 p.m., during a record review, Resident 35's clinical record indicated she was admitted to the facility on 3/19/19 with diagnoses including, but not limited to: schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A review of Resident 35's physician order dated 3/19/19 indicated she was prescribed clonazepam (a medication used to treat mental illness) 1 mg at bedtime for "schizophrenia manifested by agitation." A review of Resident 35's physician order indicated there were no orders for facility staff to monitor "agitation" or adverse effects related to the use of clonazepam. A review of PC notes dated 4/15/19 indicated the PC requested the attending physician to provide clinical rationale regarding the choice of clonazepam to treat schizophrenia as clonazepam was not typically a medication used to treat schizophrenia. The PC also requested the attending physician to provide clarity on the behavior of "agitation" as it was a "vague" indication of a manifestation of behavior related to schizophrenia. The PC also requested the attending physician to monitor Resident 17 for behaviors of "agitation" and adverse effects related to the use of clonazepam (such as drowsiness, dizziness). A review of Resident 35's clinical record indicated she had not been evaluated by a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 46 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 psychiatrist since admission to the facility and no other documentation regarding the diagnosis of schizophrenia, the clinical rationale to continue the use of clonazepam, or what behaviors constituted "agitation" could be found. A review of Resident 35's March 2019 MAR indicated the resident was not being monitored for behaviors of "agitation" or any adverse effects related to the use of clonazepam. On 04/30/19 at 9:39 a.m., Resident 35 was observed to be asleep in her room lying on her bed. On 05/01/19 at 1:30 p.m., during an interview, the DON confirmed there was no order to monitor behaviors or side effects related to clonazepam for Resident 35. The DON acknowledged Resident 35 was a fall risk (her most recent fall having occurred 4/2/19) and the use of clonazepam could increase risk for falls. The DON stated the facility had not arranged for Resident 35 to receive a psychiatric consult, and did not know why the resident had a diagnosis of schizophrenia if the target behavior was only "agitation." The DON agreed that clonazepam was not typically used to treat schizophrenia and stated she would try to obtain records from before Resident 35's admission to the facility to gain further insight as to why she was diagnosed with schizophrenia, and why only clonazepam was chosen to treat it. On 05/02/19 at 8:40 a.m., during an interview, the DON stated according to her hospice (end of life care) provider, the diagnosis of "schizophrenia" came from a diagnoses she received in February 2019 from a psychiatrist Resident 35 had seen prior to the admission to the facility. The DON stated she did not have a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 47 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 copy of that psychiatrist's evaluation and most likely would not be able to obtain it in a time frame. On 05/02/19 at 9:12 a.m., Resident 35 was again observed to be asleep in her room, lying on her bed with her eyes closed. During a concurrent interview, Resident 35's roommate (18) stated "she sleeps at lot." On 05/02/19 12:00 p.m., during an interview, the DON stated that psychiatrist visits must be arranged in cooperation with Resident 35's hospice provider and that no one from the facility had yet reached out to arrange it until yesterday (5/1/19) after interview with the survey team. The DON stated at that time she also arranged to have Resident 35's attending physician add orders for facility staff to monitor for behaviors and adverse effects related to the use of clonazepam. d. On 05/01/19 at 7:36 a.m., during a record review, Resident 107's clinical record indicated he was admitted to the facility on 4/28/19 with diagnoses including, but not limited to: insomnia (the inability to sleep) due to medical condition. A review of Resident 107's physician order dated 4/28/19 indicated he was prescribed zolpidem (a mediation used to treat insomnia) 10 mg by mouth as needed for "inability to sleep." However, the physician order did not show the PRN treatment with zolpidem was to be limited to only 14 days. The order for zolpidem did not include a stop date. On 05/01/19 at 9:30 a.m., during an interview, the licensed vocational nurse (LVN 1) confirmed Resident 107's zolpidem was in the medication cart and was in a unit dose card containing 30 doses, but the resident had not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 48 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 received any doses yet. On 05/01/19 at 9:35 a.m., during an interview, the DON confirmed the order for zolpidem was intended to be used only as needed, had no stop date, and was not limited to only 14 days. The DON Stated that sometimes the nurses call the prescribing physicians after they receive the orders to add a stop date later, but it had not been done yet for Resident 107's zolpidem because the resident was only admitted to the facility two days ago. According to the facility's undated policy titled "Psychoactive Agents" indicated the purpose of the policy was to ensure "mediations are only used when necessary, at the lowest effective dosage, prompt identification and reporting of medication side effects, and summaries of the behavior data of the resident, indicating responds to drugs and non-drug modalities and recommendations for changes are provided to the physician or prescriber." The policy also indicated that "behavioral interventions and other non-drug modalities will be encouraged prior to the initiation of psychoactive agents, psychoactive agents will be given only when necessary, and the goal of psychoactive therapy will be to give the agents at the lowers effective dose." The policy further indicated that "All residents receiving medication(s) prescribed for control of a specific behavior or manifestation of a disordered thought process shall be monitored for effectiveness and adverse drug reactions."

F759 SS=D Free of Medication Error Rts 5 Prcnt or More CFR(s): 483.45(f)(1)

F759 05/29/2019 §483.45(f) Medication Errors. The facility must ensure that itsFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 49 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 §483.45(f)(1) Medication error rates are not 5 percent or greater; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure it was free of medication error rate of five percent (%) or greater, as evidenced by the identification of two errors observed out of 29 total opportunities for error, to yield a cumulative error rate of 6.9 %, for two residents reviewed (7, 34). The errors were as followed: a. Resident 7 received a form of an iron supplement that was different than the one ordered by his attending physician. b. Resident 34 received a form of aspirin (a medication used to prevent blood clots) that was different than the one ordered by her attending physician. The deficient practice of failing to administer medication in accordance with the attending physician's orders increased the risk of Resident 7, and 34 experiencing adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) related to their medication therapy. This increased the potential for Resident 7, and 34 to experience a negative impact to their health and well-being. Findings: a. On 4/30/19 at 9:15 a.m., the licensed vocational nurse (LVN 1) was observed administering an aspirin 81 milligram (mg) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 50 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 chewable tablet to Resident 34. Resident 34 was observed swallowing the mediation whole with water. On 4/30/19 at 11:00 a.m., during a record review, the physician's order dated 12/8/17 indicated Resident 34 was prescribed "Aspirin Tablet 81 mg" once daily with food. The order did not indicate the medication should be given in chewable tablet form. The clinical records contained no documentation the resident should be given the chewable form of aspirin or the aspirin should be crushed or chewed by Resident 34. On 4/30/19 11:23 a.m., during an interview, LVN 1 stated she gave Resident 34 the chewable form of aspirin 81 mg but acknowledged the physician order did not specify the chewable form of aspirin. LVN 1 stated she did have the enteric coated ([EC] a coating used to help prevent aspirin from irritating the stomach) tablet available in her medication cart. LVN 1 stated there was a risk of stomach irritation to the resident if the EC form was not given. LVN 1 stated she gave the chewable form because the order did not specify that it should be EC form. LVN 1 stated she will clarify the order with the prescribing physician. b. On 5/01/19 at 08:12 a.m., LVN 2 was observed administering ferrous sulfate (an iron supplement) 220 mg/5 milliliter (ml) solution to Resident 7 via gastronomy tube ([g-tube] a device surgically implanted into the stomach to help with food and medication administration). On 5/01/19 at 8:45 a.m., during a record review, the physician order for Resident 7 dated 2/26/18 indicated the attending physician order for an iron supplement was intended to be for polysaccharide iron complex (a form of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 51 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 iron intended to be less irritating to the stomach than ferrous sulfate). On 5/01/19 at 09:15 a.m., during an interview, LVN 2 stated he gave the incorrect form of iron to Resident 7. LVN 2 stated the form of medication he gave was ferrous sulfate but the order specified it should had been iron polysaccharide complex instead. LVN 2 stated the only version of iron currently available in his medication cart was ferrous sulfate solution and he did not have the iron polysaccharide complex. LVN 2 stated he did not know the difference between ferrous sulfate and an iron polysaccharide complex or the potential impact of giving the wrong one to Resident 7. According to the facility's undated policy titled "Administering Medications" indicated that "Medications must be administered in accordance with the orders including any required time frame."

F761 SS=E Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 05/29/2019 §483.45(g) Labeling of Drugs and Biologicals 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. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 52 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 keys. §483.45(h)(2) 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. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review the facility failed to: Ensure the temperatures of the medication storage room and the refrigerator used to store the resident's medications were monitored regularly, and consistently. Store one bottle of lorazepam intensol (a medication used to treat mental illness) 2 milligram (mg)/milliliter (ml) oral solution according to the manufacturer's specifications. Ensure that medications are not relabeled except by a pharmacist. Ensure that expired medications were removed from medication stock and disposed of properly. The deficient practices of failing to store and label medications appropriately, monitor medication storage conditions properly, or discard medications which are expired increased the risk of the facility's residents receiving medications which may have become ineffective or toxic resulting in a negative FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 53 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 impact on their health and well-being. Findings: a. On 04/30/19 at 01:26 p.m., during an observation of the medication storage room, the temperature of the room was observed to be at 75 degrees Fahrenheit (F) and the temperature of the refrigerator used to store medications was 42 degrees F. A review of the April 2019 Room Temperature log indicated the facility staff failed to document the room temperatures for the 7-3 shift on the following dates: 4/6/19, 4/7/19, 4/13/19, 4/14/19, 4/21/19, 4/28/19, 4/29/19, and 4/30/19. During a concurrent interview, on 04/30/19 at 01:26 PM, the registered nurse (RN 1) stated most likely the staff had forgotten to document the temperatures on the missing dates. b. During an observation of the medication storage refrigerator, on 04/30/19 at 01:26 p.m., a vial of Procrit (an injectable medication used to increase red blood cells) was found in a different prescription bag with a pharmacy label indicating that it was Phos-Nak powder packs (a powder medication used to treat kidney conditions). The vial was observed to be used and the manufacturer's label indicated it was "single use only" meaning that once it was used, it should be discarded. During a concurrent interview, RN 1 stated they keep the Procrit in the refrigerator even after it is used as a reminder they need to reorder it for the resident. RN 1 stated she could not explain why the medication had been placed into a different bag and labeled as Phos-Nak. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 54 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 c. During observation of the medication refrigerator, on 04/30/19 at 01:26 p.m., revealed a bottle of Roxane (brand) lorazepam intensol 2 mg/ ml oral solution containing 15 ml of product was found removed from the manufacturer's original bottle and placed in a prescription bottle labeled by the dispensing pharmacy. The bottle did not contain a date when the medication was removed from the manufacturer's original bottle or the date the original manufacturer's bottle was opened. The fill date on the prescription label was 3/19/19 and the expiration date labeled on the prescription bottle was January 2020. On 04/30/19 at 02:21 p.m., during an interview, RN 1 stated she was not aware of the manufacturer's storage requirements for lorazepam oral solution and the facility did not have a reference on site to verify that sort of information. RN 1 indicated they relied on the dispensing pharmacy to give them the correct information. During a concurrent interview, on 04/30/19 at 02:21 p.m., in an attempt to verify the correct storage conditions for the lorazepam oral solution, RN 1 placed a telephone call to the hospice pharmacy who had originally dispensed the product. RN 1 asked to speak to the pharmacist and was transferred to a line that went straight to voicemail. RN 1 left a voice mail asking the pharmacist to return her call to verify the correct information. On 04/30/19 at 02:21 p.m., RN 1 then placed a telephone call to the pharmacy with whom the facility contracts for the majority of pharmacy services. RN 1 asked to speak to a pharmacist who told her that lorazepam oral solution would be good for one year from the date that it was dispensed even if it had been removed from the original bottle. However, RN 1 stated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 55 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 information was incorrect, then RN 1 placed a call to the pharmacy nurse consultant (an individual that inspects the pharmacy services of the facility on a regular basis). The nurse consultant stated she did not know the exact storage conditions, but would check on it and call back. RN 1 then placed a call to the hospice provider's nurse practitioner to inform her she needed to speak with a pharmacist at the hospice pharmacy regarding the proper storage conditions of lorazepam oral solution. The nurse practitioner was able to conference in one of the hospice pharmacy's pharmacists to the call. The hospice pharmacist stated it was acceptable to dispense lorazepam oral solution outside of the manufacturer's original container and that it would not expire until one year from the dispensing date or the manufacturer's printed expiration date, whichever came first. RN 1 asked the hospice pharmacist to find a stock bottle of the lorazepam oral solution in the pharmacy refrigerator and read the package labeling. RN 1 stated "I just want to make sure this is safe to give to my resident." However, the hospice pharmacist was adamant the information given to RN 1 was correct, but then offered to replace the prescription in order to appease RN 1. During interview, RN 1 declined and asked the hospice pharmacist again to check the product labeling on the manufacturer's original bottle, however, the hospice pharmacist again refused claiming she needed to "protect her license." During an interview, on 04/30/19 at 03:04 p.m., the pharmacy nurse consultant called the facility and stated to RN 1 that lorazepam oral solution should only be dispensed in the manufacturer's original bottle and once the bottle was opened, it should be labeled with the open date as it would only good for 90 days. A review of the Roxane brand manufacturer's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 56 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 labeling for lorazepam intensol 2 mg/ ml indicated to "Dispense only in this bottle and only with the calibrated dropper provided" and "discard opened bottle after 90 days." On 04/30/19 at 03:10 p.m., during an interview, the director of nursing (DON) stated the facility did not have any reference on site to verify manufacturer's storage specifications. The DON stated they "rely heavily" on the pharmacy to tell them correctly how to store medications properly. The DON stated she would have to speak to the hospice pharmacy about the misinformation given to RN 1 and would request that the bottle of lorazepam oral solution, dispensed incorrectly, be replaced immediately. According to the facility's undated policy titled "Drug Storage and Labeling" indicated that "drugs will be labeled in accordance with state and federal laws. The pharmacist is the only person allowed to change information on a prescription (Rx) label." The policy also indicated that "All medications requiring an open date will be dated immediately upon opening. Date will be applied using a 'Date Open' label or written directly on the packaging by the charge nurse" and "To insure potency, maintain efficacy and avoid cross contaminations, certain medications must be dated when first opened and discarded when the designated expiration time period or the manufacturer's expiration date elapses."

F812 SS=D Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 05/29/2019 §483.60(i) Food safety requirements. The facility must FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 57 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, facility staff failed to wear hair net, and beard net/guard with visible beard, while in the food preparation area. These deficient practices had the potential to cause foodborne illnesses (Illness caused by food contaminated with bacteria, viruses, parasites, or toxins) due to unsafe food handling practices. Findings: During the initial tour of the facility's kitchen on 4/30/19 at 7:45 a.m., Dietary Supervisor (DS) and Kitchen staff/Cook (Cook 1) was observed with visible beard, but staff were not wearing a beard net/guard while in the food preparation area. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 58 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 During an observation on 4/30/19 9:33 a.m., Activity Assistant (AA) was seen entering the kitchen without wearing a hairnet. AA was observed walked past the preparation area. During an interview on 5/1/19 at 12:00 noon, DS stated they did not have beard net/guard available. DS also stated they usually had shaved beards. A review of facility's policy and procedures titled "Procedure for Refrigerated Storage" dated 3/13 indicated: Individual packages of refrigerated or frozen food taken from the original packing box need to be labeled and dated.

F813 SS=D Personal Food Policy CFR(s): 483.60(i)(3)

F813 05/29/2019 §483.60(i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, facility failed to ensure proper storage of three out of seven foods for residents from outside sources. This deficient practice had the potential for resident to lose their food brought to them by their families and may cause foodborne illnesses due to not dating the foods. Findings: During an observation and interview on 4/30/19 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 59 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 at 12:59 p.m., one small refrigerator was observed in the resident's dining and activity room. The activity director (AD) stated families brought some foods for the residents and staff stored them in the resident's common refrigerator. During an observation, inside the refrigerator was an unopened one whole loaf of white bread and one pack of unopened cookies. There was one opened bottle of guava, banana, and moringo juice, marked with a resident name but it was not dated as to when it was opened. During an interview AD stated, two of the resident's family handed the white bread and cookies to her on the same day (4/30/19) around 10:30 a.m. AD stated she put the foods inside the refrigerator and was planning to ask a certified nursing attendant to label them later. AD further stated, she already knew the families so she would not forget which foods belonged to whom, and what day they were brought in. During an interview, on 5/01/19 2:53 p.m., Registered Nurse (RN 1) stated, families could bring foods for the residents but they needed to stop at the nurse's station or staff would ask licensed nurse to check the resident's diet. RN 1 stated once the foods needed to be refrigerated, staff would label them with name and dates. During an interview, on 5/2/19 at 9:22 a.m., Director of Nursing (DON) stated when families asked staff to store food for residents, it should be labeled with name and date right away. A review of an undated facility's policy and procedures titled "Food for Residents from Outside Sources," indicated the following: 1. Non-perishable foods such as cookies can be stored in the residents' room or at the Nurse's station with the resident's name and date of storage. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 60 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 2. Food or beverages should be labeled and dated to monitor for food safety. Food or beverages in the original containers marked with manufacturer expiration dates and unopened, need to be marked with resident's name. 41.

F880 SS=E Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 05/29/2019 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 61 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: b. On 05/02/19 at 09:40 a.m., during a review of the facility's IPCP program, the IPCP plan did not contain a written list of communicable diseases or instructions on how, when, or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 62 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 whom to report possible incidents of communicable diseases. During a concurrent interview, the assistant director of staff development (ADSD) stated he served as the facility's infection preventionist (person designated by the facility to be responsible for the IPCP). The ADSD stated the IPCP did not contain a written list of communicable diseases and thought incidents of communicable disease were reported "to the state." According to the facility's undated policy titled "Infections Prevention and Control Program" indicated under the section "outbreak management" that "Outbreak management is a process that consists of: reporting the information to the appropriate public health authorities" and "The medical staff will help the facility comply with pertinent state and local regulations concerning the reporting and management of those with reportable communicable diseases." Based on observation, interview and record review, facility failed to ensure universal precautions (developed to control spread of infection) and contact isolation (used for infections, diseases or germs that are spread by touching the patients or items in the room) precaution was observed for two of 14 sampled residents (20, 50). The staff failed to ensure the following was implemented: a. Change cleaning cloth in disinfecting and sanitizing furniture or equipment being used by two residents (20 and 50) residing in the same room designated as an isolation room. b. Wear proper personal protective equipment ([PPE] equipment worn to minimize exposure to hazards that cause serious workplace FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 63 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 injuries and illnesses.) c. Wash hands after removing gloves and before entering other resident's room. d. Include in its infection prevention and control program ([IPCP] a comprehensive program used to help recognize, prevent, and help control the spread of infection in the facility) a written list of communicable diseases (diseases that can be spread from person to person), including instructions on when, and whom to report possible incidents of communicable diseases. These deficient practices increased the risk of Resident 20, and 50, and possible communicable disease in the facility, spread from resident to resident, staff, and visitors, before it was identified or reported potentially causing serious health complications resulting in hospitalization, and/or death. Findings: a. During an observation and interview on 5/1/19 at 10:54 a.m., Housekeeper (HK 1) was observed inside the isolation room (housing Resident 20, and 50) wearing only gloves. During an interview, HK 1 about cleaning and disinfecting (are antimicrobial agents that are applied to the surface of non-living objects to destroy microorganisms that are living on the objects) procedures, stated she would wear gloves, clean the bed tables, and the room with disinfectant spray and one green "trapo" (nondisposable cleaning cloth). HK 1 stated she used bleach and different cleaning cloth for the restrooms. HK 1 also stated, she would change her gloves in between cleaning bed B and C, and verified that HK 1 would only use gloves FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 64 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 when cleaning isolation room even after pointing out contact isolation sign visible outside the room. HK 1 further stated, she used only 1 green cleaning cloth per room and the restroom. During an interview on 5/2/19 at 7:03 a.m., Maintenance supervisor (MS) stated the proper way of disinfecting contact isolation rooms was for housekeeping staff to use one cleaning cloth per resident's bed and one cleaning cloth for the restroom. A review of Resident 20's face sheet (admission record), indicated an admission date of 2/27/19 with diagnoses of essential hypertension (high blood pressure), benign prostatic hyperplasia (prostate enlargement in men) and extended spectrum beta-lactamases urine ([ESBL] producing bacteria can not be killed by many of the antibiotics that doctors used to treat infections discovered in urine). A concurrent review of Resident 20's Minimum Data Set (MDS), a standardized assessment and care screening tool, section titled "Functional Status" (individual's ability to perform normal daily activities required to meet basic needs) indicated Resident 20 needed extensive assistance with bed mobility, transfers, and was totally dependent on bathing. A review of Resident 20's medical record (health record) dated 4/30/19 indicated Resident 20 was re-admitted on 4/27/19 at 11:00 a.m. The record indicated a urinary results for culture and sensitivity (culture determines what organism causing an infection; sensitivity determines how the organism can best be treated) was received from acute hospital on 4/30/19. The records indicated Resident 20 was placed on contact FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 65 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 isolation at 9:00 p.m. for ESBL urine and intravenous antibiotic (liquid antibiotic delivers directly into a vein) was started. A review of Resident 50's face sheet (admission record), indicated an admission date of 1/14/19 with diagnoses of muscle weakness, gait, and mobility abnormalities. A concurrent review of Resident 50's MDS assessment titled "Functional Status" indicated Resident 50 needed extensive assistance with bed mobility, and was totally dependent on transfer, bathing and toilet use. b. During an observation on 5/02/19 at 7:43 a.m., Certified Nursing Assistant (CNA 7) was observed entering another resident's room, across the hallway, after removing her gloves and leaving the isolation room. Assistant Director of Staff Development (ADSD) verified that CNA 7 did not use hand gel nor washed hands after leaving an isolation designated room. A review of facility's policy and procedures titled "Policy for Multi-Drug Resistant Organism (MDRO-common bacteria/germs that have developed resistance to multiple types of antibiotics) dated 3/14/19 indicated, 1. Standard Precautions - Apply to all contact with resident's blood, body fluids, secretions and excretions regardless of the presence of visible blood, non-intact skin and mucous membranes. 2. Standard Precautions including Contact Precautions. a. Hand Hygiene: Perform before and after every resident contact, and before and after removing gloves. b. Protective Barriers: Gowns- Wear gowns when it is anticipated that clothing will become soiled with blood or other body fluids or when FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 66 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 contact with soiled surfaces (such as side rails (bedrails) or bed linens of an infected resident) is anticipated. A review of facility's undated staff training record, indicated the following: 1. Facility considers hand hygiene the primary means to prevent the spread of infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. 3. Employees must wash their hands for at least fifteen (15) seconds using antimicrobial soap and water before and after entering isolation precaution settings.

F881 SS=E Antibiotic Stewardship Program CFR(s): 483.80(a)(3)

F881 05/29/2019 §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to: a. Include in its infection prevention and control program ([IPCP] a comprehensive program used to help recognize, prevent, and help control the spread of infection in the facility) a standardized clinical criteria used to guide the selection and duration of antibiotic (medications used to treat infections) therapy FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 67 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 when necessary to treat residents who have been determined to have a true infection (the establishment of an infective agent in or on a suitable host, producing clinical signs and symptoms). b. Establish a system to monitor for the use of antibiotics in the facility for one of 14 sampled residents (36). These deficient practices increased the risk that: Residents may receive treatment with antibiotics not best suited to treat their infections or for a suboptimal period of time resulting in their infection not being treated appropriately or completely. Residents may experience preventable adverse effects (unwanted, uncomfortable, or dangerous effects which may impair a resident's ability to function at their highest possible level of physical, mental, and psychosocial well-being) related to antibiotic use including, but not limited to: nausea, vomiting, and diarrhea. Antibiotic therapy may become ineffective at treating residents' future infections. Findings: a. On 05/02/19 at 09:40 a.m., during a review of the facility's IPCP program, the IPCP plan did not contain any written standardized protocols or clinical criteria to help guide the appropriate selection and duration of antibiotic therapy in the residents determined to have true infections. The IPCP also did not contain any data or the trends of antibiotic usage or any tools with which to communicate antibiotic FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 68 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 prescribing trends to the facility's prescribing physicians. b. During a record review, Resident 36's clinical record indicated he was admitted to the facility on 6/21/18 including, but not limited to: shortness of breath. The clinical record indicated Resident 36 had recently returned from a general acute care hospital (GACH) where he was evaluated on 4/25/19 for "aggressive behavior, screaming and yelling, trying to hit staff." During his stay at the GACH, he was prescribed amoxicillin-clavulanic acid (an antibiotic used to treat bacterial infection) 875 milligrams (mg) twice daily for 10 days due to a possible urinary tract infection ([UTI] an infection in any part of the urinary system, the kidneys, bladder, or urethra) on 4/25/19. A review of Resident 36's physician order indicated on 4/26/18, during readmission to the facility, the physician ordered amoxicillinclavulanic acid to continue until 5/6/19 due to "UTI." A review of the Surveillance Data Collection Form for UTI (a clinical tool used as part of the IPCP to determine if the resident's symptoms indicate the presence of a true infection) dated 4/26/19 indicated the facility's infection preventionist (person designated by the facility to be responsible for the IPCP) determined Resident 36 "does not meet criteria" of a true infection. However, Resident 36's clinical record contained no evidence the result of the infection determination was communicated to the prescribing physician. There was no evidence Resident 36's order for amoxicillinclavulanic acid was discontinued. During a concurrent interview, On 05/02/19 at 09:40 a.m., the assistant director of staff development (ADSD) stated he served as the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 69 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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's infection preventionist. The ADSD stated there was no data kept on trends of antibiotic usage, no communication of antibiotic prescribing trends to the facility's prescribing physicians, and no written protocols on the selection of antibiotics present in the IPCP. The ADSD stated that antibiotic selection to treat infections was at the sole discretion of the prescribing physician and the facility did not evaluate the use of antibiotics after they were prescribed. The ADSD stated he evaluated Resident 36 for a true infection due to UTI on 4/26/19 and determined the resident did not fit the criteria for a true infection. The ADSD stated Resident 36's order for amoxicillinclavulanic acid had not been stopped. ADSD stated even though it was determined Resident 36 did not meet the clinical criteria for a true infection, the information was not communicated to the physician "yet." The ADSD stated there was not a policy or timeframe by which the facility's staff are expected to communicate this information back to the prescribing physician. The ADSD stated Resident 36's antibiotic order for amoxicillinclavulanic acid was not evaluated or reviewed in any way to determine if it was an appropriate selection or duration before the order was continued when the resident was readmitted back to the facility. According to the facility's policy dated 5/30/2018 titled "Antimicrobial Stewardship Program" indicated the facility had a responsibility to "review and monitor antibiotic usage patterns on a regular basis" and "include a separate report for the number of residents on antibiotics that did not meet criteria for active infection." The policy further indicated "feedback will be given to physicians on their individual prescribing patterns of cultures ordered and antibiotics prescribed, on a regular basis." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 70 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

F912 Bedrooms Measure at Least 80 Sq Ft/Resident F912 CFR(s): 483.90(e)(1)(ii) SS=B ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 05/29/2019 §483.90(e)(1)(ii) Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to meet the required 80 square feet (sq ft) for each resident in multiple resident bedrooms for 11 of 23 resident's rooms. The resident Rooms included 1, 3, 4, 5, 6, 7, 8, 9, 10, 14, and 16 which did not meet the regulation, placing the residents at risk for lack of privacy, safety concerns during care, and emergency services. Findings: During an interview with the Administrator (ADM) on 5/02/19 at 1:35 p.m., stated that 23 residents in 11 rooms were affected by having bedrooms measuring less than 80 sq ft per person. The ADM provided a letter dated 4/30/19, requesting a room waiver for the resident room sizes of less than 80 sq ft per resident for 11 of 23 rooms. The following resident Rooms measured as followed: Room Number of Beds 1 3 224.40 Total Square feet FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 71 of 72 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: _______________ 555218 (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ST. ANDREWS HEALTHCARE 2300 W Washington Blvd Los Angeles, CA 90018 (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 3 3 224.40 4 3 224.40 5 3 224.40 6 3 224.40 7 3 224.40 8 3 224.40 9 3 224.40 10 3 224.40 14 3 231.24 16 3 231.24 During the Recertification survey observations on 4/30/19 to 5/2/19, revealed the residents had reasonable amount of privacy, closet and storage space. The bedside stands were present in each of the rooms and there was sufficient room for the provision of nursing services for these group of the residents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MYW111 Facility ID: CA970000052 If continuation sheet 72 of 72