Woods Health Services

F-F758

Findings:

During a review of an Admission Record indicated Resident 13 was readmitted to the facility on [DATE REDACTED] with diagnoses that included dementia (a decline in mental ability severe enough to interfere with daily life) with psychotic (a serious mental illness characterized by lost contact with reality) disturbances, anxiety (a feeling of worry, nervousness, or unease) and depression (causes feelings of sadness).

During a review of Resident 13's PO, the MDO indicated on 7/17/2023 to administer Simvastatin 20 mg at bedtime (HS).

During a review of Resident 13's physician orders (PO), the physician's order dated 2/5/2024 indicated to administer Famotidine (used to treat stomach ulcers) 20 milligrams (mg) twice a day (BID) by mouth (PO).

During a review of Resident 13's History and Physical, dated 7/7/2024, the History & Physical indicated Resident 13 did not have the capacity to understand and make decisions.

Further review of the physician's orders dated 8/22/2024 indicated to administer Pantoprazole (used to treat stomach ulcers) 40 mg PO every morning (QAM) and an order dated 11/14/2024, indicated to administer Seroquel 25 milligrams (mg. by mouth at bedtime.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 25 056083 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056083 B. Wing 04/04/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woods Health Services 2600 A Street LA Verne, CA 91750

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 During a review of the Note to Attending Physician/Prescriber ([NAME]), from the facilities pharmacist, dated 1/12/2025, the [NAME] indicated the resident took the following medications: Famotidine 20 mg PO BID Level of Harm - Minimal harm or (2/2024) and Pantoprazole 40 mg PO QAM (2/2024). Please reevaluate the continued use of both potential for actual harm (medications). The [NAME] portion titled Physician/Prescribers Response, was left blank. The [NAME] did not indicate any documentation from Resident 13's physician whether the physician agreed or disagreed with Residents Affected - Some the pharmacist recommendation.

During a review of Resident 13's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 1/25/25, the MDS indicated Resident 13 was severely cognitively impaired and required supervision (helper provides verbal cues) with toilet hygiene, shower and bathing.

During a review of the facility's Consultant Pharmacist Medication Regimen Review (CPMRR), from the facility's pharmacist, dated 2/9/2025, the CPMRR indicated Resident 13 took Simvastatin 20 mg PO HS and to please consider discontinuation of use.

During an interview with the Hospice Registered Nurse (HRN), on 4/3/2025 at 10:31 am, the HRN stated the HRN was not aware of the pharmacist recommendation regarding Simvastatin. HRN stated any new development regarding Resident 13 was usually relayed by HRN to the resident's physician. HRN stated ultimately the physicians were the ones responsible for the care of the resident, so informing the physician was very important.

During a record review of a document titled Note to Attending Physician/Prescriber ([NAME]), from the facilities pharmacist, dated 3/9//2025 indicated Resident 13 had taken Seroquel 25 mg PO HS since November 2024. Please consider a dose reduction to 12.5 mg PO HS. If a gradual dose reduction (GDR) is contraindicated, please specify why. The [NAME] portion titled Physician/Prescriber Response, was left blank. The [NAME] did not indicate any documentation from the Resident 13's physician whether the physician agreed or disagreed with GDR.

During an interview with Registered Nurse Supervisor 1 (RN 1), on 4/2/2025 at 3:41 pm, RN 1 stated it was important to follow the pharmacist recommendations and to inform the resident's physician for the benefit of

the resident and their overall health.

During an interview with the Director of Nursing (DON), on 4/4/2025 at 8:34 am, the DON stated the pharmacist recommendations should be followed because the pharmacist is specialized in medications regarding the use and drug interactions. Physicians should always be informed and they in turn need to respond in a timely manner because we want to ensure the resident will take the correct appropriate medication and dosages based on their medical conditions. The Physicians should be informed of the pharmacist recommendations within a one - two-day period.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 25 056083 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056083 B. Wing 04/04/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woods Health Services 2600 A Street LA Verne, CA 91750

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 During a review of the facility's policy titled Medication Regimen Review, revised on 5/2019, indicated the consultant pharmacist reviews the medication regimen of each resident at least monthly. The goal of the Level of Harm - Minimal harm or MRR is to promote positive outcomes while minimizing adverse consequences and potential risk associated potential for actual harm with medications. An irregularity refers to the use of medication that is inconsistent with accepted pharmaceutical services standards of practice; is not supported by medial evidence; and/or impedes or Residents Affected - Some interferes with achieving the intended outcomes of pharmaceutical services. If the identified irregularities represent a risk to a person's life, health, or safety, the consultant pharmacist contacts the physician immediately (within one hour) to report the information to the physician verbally and documents the notification. If the physician does not provide a timely or adequate response, or the consultant pharmacist identified that no action has been taken, he/she contacts the medial director or the administrator. The attending physician documents in the medical record that the irregularity has been reviewed and what action was taken to address it.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 25 056083 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056083 B. Wing 04/04/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woods Health Services 2600 A Street LA Verne, CA 91750

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50016

Residents Affected - Few Based on observation, interview, and record review, the facility failed to proper food storage and ensure sanitary conditions were followed by failing to:

A. Ensure food past it's use-by date was not stored in one of one walk-in refrigerator (Refrigerator 1) observed in the kitchen.

B. Ensure staff were completing the sanitation bucket log, ice machine log, and dish machine log daily.

These deficient practices placed the residents at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages).

Findings:

A. During an observation on 4/1/2025 at 09:45 AM, in the kitchen, the Refrigerator 1 had 5 beef base containers stored and were labeled with a past best if used by date of 2/23/2025.

During an interview on 4/1/2025 at 10:14 AM, with the dietary supervisor (DS), the DS stated the facility should ensure food in Refrigerator 1 was not stored past its best if used by [date], because this ensured food safety, prevented contamination, and complied with health regulations. The DS stated food past the best if used by date should not be stored in Refrigerator 1, and should be discarded because the food could potentially cause a foodborne illness if served to the residents.

During a review of the facility's policy and procedure (P&P) titled Food and Supply Storage, dated revised 1/2023, the P&P indicated:

All food, non-food and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption.

Most, but not all, products contain an expiration date. The words sell-by, best-by, enjoy-by, or use-by should precede the date. The sell-by date is the last date that food can be sold or consumed; do not sell products in retail areas or place on patient tray's/resident plates past the date on the product. Foods past the use by, sell-by, best-by, or enjoy by date should be discarded.

B. During a review of the kitchen's logs on 4/1/2025 at 10:01 AM, the logs for the month of March indicated

the logs were incomplete:

The Red Bucket Log (sanitation) indicated that the concentration of the quaternary sanitizer solution (ammonium solution used for sanitizing surfaces) was not tested on [DATE REDACTED] at 2:00 PM, 4:00 PM, and 06:00 PM as no test record was noted. The sanitation bucket log was missing the manager's initials in the weekly

review section.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 25 056083 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056083 B. Wing 04/04/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woods Health Services 2600 A Street LA Verne, CA 91750

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 The Ice Machine Cleaning Log indicated the ice machine was not cleaned on 3/30/2025 during the morning shift. The log indicated to clean ice machine twice daily. Level of Harm - Minimal harm or potential for actual harm The Dishmachine Temperature Record (low temperature machine), the record indicated the dish machine temperature and chlorine rinse was not checked for dinner on 3/31/2025. The dish machine log was missing Residents Affected - Few the manager's initials in the weekly review section.

During an interview and record review on 4/1/2025 at 10:01 AM, the sanitation bucket log, ice machine cleaning log, and dish machine temperature record were reviewed with the DS. The DS stated the sanitation bucket log, the ice machine cleaning log, and the dish machine temperature record were incomplete. The DS stated it was important to ensure staff were completing all kitchen logs accurately and daily for several reasons, such as: regulatory compliance, infection control & resident safety, accountability and consistency, equipment functionality and maintenance, and quality assurance. The DS stated record keeping provided clear paper trail that procedures were being followed and completed. The DS stated when managers consistently reviewed and initialed the logs, it reinforced the importance of sanitation and sets expectations for the rest of the team.

During a review of the facility's P&P, titled Sanitizing Food Contact Surfaces revision date 1/2023, the P&P indicated the Director/Designee:

-Verifies completion of logs; initials forms weekly.

-Retains the following logs for three (3) months:

-Pot-Sink Temperature & Sanitizer Concentration Log

-Sanitizer Solution from Dispenser

-Red Bucket Log

During a review of the facility's policy and procedure (P&P) titled Dish Machine Temperatures revision dated 1/2023, the P&P indicated the Director/Designee:

-Verifies completion of logs; initials forms weekly.

-Retains dish machine temperature records for one (1) year.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 25 056083 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056083 B. Wing 04/04/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woods Health Services 2600 A Street LA Verne, CA 91750

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm 50016

Residents Affected - Few Based on interview and record review, the facility failed to ensure accurate discharge disposition medical

record documentation for one of one sample resident (Resident 50).

This deficiency resulted in incomplete and potentially misleading information regarding the Resident 50's discharge status.

Findings:

During a review of Resident 50's Admission Record (AR), the AR indicated the facility admitted Resident 50

on 2/7/2025, with diagnoses including atrial fibrillation (an irregular heartbeat that occurs when the electrical signals in the atria [the two upper chambers of the heart] fire rapidly at the same time), shortness of breath, and muscle weakness (generalized).

During a review of Resident 50's Discharge Planning Review, undated, admitted d 2/7/2025, the review indicated Resident 50 requested a discharge to another long-term care center.

During a review of Resident 50's History and Physical (H&P), dated 2/10/2025, the H&P indicated Resident 50 had the capacity to understand and make decisions.

During a review of Resident 50's Minimum Data Set (Minimum Data Set (MDS - a resident assessment tool), dated 3/11/2025, the MDS indicated Resident 50 was discharged to a short-term general hospital.

During a review of Resident 50's Discharge Instruction Form, dated 3/11/2025, the form indicated Resident 50 was discharged to a long-term care center.

During a concurrent interview and record review on 4/3/2025 at 02:07 PM, Resident 50's Discharge Instruction Form dated 3/11/2025 was reviewed with the Minimum Data Set Coordinator (MDSC) Nurse. The MDSC stated the Discharge Instruction Form indicated Resident 50 was discharged to a long-term care facility. The MDS Nurse stated she had incorrectly documented Resident 50 as being discharged to an acute care hospital. The MDS Nurse stated accurate completion of resident information in the medical record directly impacted patient care and regulatory compliance.

During an interview on 4/4/2025 at 9:35 AM, with the Director of Nursing (DON), the DON stated accurate [documentation] in the medical record was the foundation of quality care. The DON stated [accuracy of medical records] guided the facility in developing the residents plan of care and helped ensure the residents needs were met. The DON stated accurate documentation of a resident's discharge status determined follow-up care, services, and support they received. The DON stated inaccurate discharge disposition could affect the resident and could potentially affect the help they needed after leaving the facility. The DON stated

an inaccurate discharge disposition could negatively impact the resident and potentially hinder access to necessary post-discharge assistance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 25 056083 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056083 B. Wing 04/04/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woods Health Services 2600 A Street LA Verne, CA 91750

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 During a review of the facility's Policy and Procedure (P&P) titled, Charting and Documentation revision date 7/2017, the P&P indicated documentation in the medical record will be objective (not opinionated or Level of Harm - Minimal harm or speculative), complete, and accurate. potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 25 056083 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056083 B. Wing 04/04/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woods Health Services 2600 A Street LA Verne, CA 91750

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38108 potential for actual harm Based on observation, interview, and record review, the facility failed to maintain infection control practices Residents Affected - Some by failing to:

a. Ensure enhanced barrier precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs, bacteria that have become resistant to certain antibiotics] in nursing homes) were followed and Personal Protective Equipment (PPE, gown, gloves, mask and face shield) were worn while providing care for Resident 47.

b. Ensure Resident 8's nasal cannula ([NC] a device-lightweight flexible plastic tubing used to deliver supplemental oxygen, tubing ending is placed in the nostrils and is fitted over the patient's ears) did not touch the floor.

c. Ensure Resident 47's NC did not touch the floor.

These deficient practices had the potential to result in the transmission of infectious microorganisms and increase the risk of infection for Residents 8 and 47.

Findings:

a. During a review of Resident 47s Admission Record (AR), the AR indicated Resident 47 was admitted to

the facility on [DATE REDACTED] with multiple diagnoses including pressure-induced deep tissue damage of the sacral region (bone at the bottom of the spine), congestive heart failure (the heart doesn't pump blood as well as it should), and depression (causes feelings of sadness and/or a loss).

During a review of Resident 47's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 3/17/2025, the MDS indicated Resident 47 had intact cognitive skills (ability to reason, make decisions) and was dependent (helper does all the effort) in oral/toileting hygiene, showering and upper body dressing.

During an observation on 4/4/2025 at 11:22 in Resident 47's room doorway, a signage was posted outside of

the resident room titled Enhanced Barrier Precautions, from the US Department of Health and Human Services, Center for Disease Control and Prevention (DCD). The signage indicated staff must wear gloves and a gown for the following high-contact resident care activities .providing hygiene for wound care (residents): with any skin opening requiring a dressing. During the same observation, Certified Nurse Assistant 2 (CNA 2) was observed within one foot of Resident 47, wiping the resident's face with a face towel, without wearing personal protective equipment.

During an interview on 4/4/2025 at 11:25 am, with CNA 2, CNA 2 stated CNA 2 should have properly gowned up prior to entering Resident 47's room and that PPE's were important to be cautions to help protect

the resident and CNA 2.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 25 056083 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056083 B. Wing 04/04/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woods Health Services 2600 A Street LA Verne, CA 91750

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an interview with the Infection Preventionist Nurse (IPN), on 4/4/2025 at 11:41 am, the IPN stated staff needed to wear full PPE's when providing care to a resident on all types of isolation; contact and Level of Harm - Minimal harm or enhanced. The IPN stated any care (washing the face, combing hair, giving baths or providing peri-care) potential for actual harm given to a resident on isolation is to protect the residents.

Residents Affected - Some During an interview with the Director of Nursing (DON), on 4/4/2025 at 11:41 am, the DON stated PPE must be worn while providing care to any resident on isolation to avoid the spread of diseases.

During of a review of the facility's policy and procedure (P&P), titled, Standard Precautions dated 5/20/2013,

the policy indicated, under Section 3. Masks, Eye Protection, Face Shields: A. Mask and eye protection or a face shield are worn to protect mucous membranes of the eyes, nose, and mouth during procedures and resident-care activities that are likely to generate splashes or sprays of blood, bodily fluids, secretions, and excretions.

During a review of the facility's in-service, titled, Infection Control Storage of Personal Belongings, dated 7/3/2023 to 7/5/2023, the in-service indicated participants would be able to understand the importance of proper storage of personal belongings. The in-service course content indicated, no personal belongings of food in resident rooms, hallways, breakrooms, medication rooms, or linen carts, e.g., sweaters, cell phones, coffee cups, water bottles.

49252

b. During a review of Resident 8's AR, the AR indicated Resident 8 was admitted to the facility on [DATE REDACTED] with diagnoses that included urinary tract infection (UTI, an infection in any part of the urinary system: kidneys, bladder, or urethra [tube through which the urine leaves the body]) heart failure (when the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen), and dysphagia (difficulty swallowing).

During a review of Resident 8's MDS, dated [DATE REDACTED], the MDS indicated Resident 8 had moderate impaired cognition (ability to understand) and was dependent (helper does all the effort and resident does none of the effort to complete the activity or two or more helpers are required to complete the activity) for personal hygiene.

During a review of Resident 8's Order Summary Report, dated active as of 4/2/2025, the Order Summary Report indicated an active physician's order, dated 3/28/2025, for continuous oxygen at three liters (unit of volume) per minute via NC.

During a concurrent observation and interview on 4/1/2025 at 11:49 AM with Licensed Vocational Nurse 1 (LVN 1) in Resident 8's room, Resident 8's NC was touching the floor at the resident's right side while Resident 8 was lying in bed. LVN 1 stated, the NC should not be touching the ground for infection control [purposes] because the resident could get a respiratory infection.

During an interview on 4/4/2025 at 10:02 AM with the DON, the DON stated the NC tubing touching the floor was not appropriate for infection control [purposes].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 25 056083 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056083 B. Wing 04/04/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woods Health Services 2600 A Street LA Verne, CA 91750

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 c. During a review of Resident 47's AR, the AR indicated Resident 47 was admitted to the facility on [DATE REDACTED] with diagnoses that included heart failure (when the heart muscle can't pump enough blood to meet the Level of Harm - Minimal harm or body's needs for blood and oxygen), depression (a mood disorder that may cause persistent sadness or loss potential for actual harm of interest in activities), and anxiety disorder (persistent feeling of dread or panic that can interfere with daily life). Residents Affected - Some

During a review of Resident 47's History & Physical (H&P), dated 3/16/2025, the H&P indicated the resident had the capacity to understand and make decisions.

During a review of Resident 47's MDS, dated [DATE REDACTED], the MDS indicated Resident 47 had intact cognition (ability to understand) and was receiving oxygen therapy.

During a review of Resident 47's Order Summary Report, dated active as of 4/1/2025, the Order Summary Report indicated Resident 47 had an active physician order, dated 3/11/2025, for oxygen at two liters per minute via nasal cannula as needed for shortness of breath.

During a concurrent observation and interview on 4/4/2025 at 9:36 AM with LVN 1 in Resident 47's room, Resident 47's NC was touching the floor. LVN 1 stated, the NC should not be touching the ground because it created a risk for infection to the resident. LVN 1 further stated, she would replace Resident 47's NC tubing.

During an interview on 4/4/2025 at 10:09 AM with the DON, the DON stated the NC touching the ground was

an infection control risk to Resident 47. The DON stated, they didn't know what type of viruses or bacteria were on the floor and what the resident could contract. The DON stated, the NC should be exchanged for a new one.

During a review of the facility's P&P, titled, Oxygen and Humidifier, undated, the P&P indicated that during oxygen delivery the oxygen delivery device must be kept clean at all times and changed as needed for cleanliness.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 25 056083