Cheviot Hills Post Acute

During an interview on 2/20/2026 at 12:38 PM with the registered dietitian (RD - a food and nutrition expert who can translate the science of nutrition into practical solutions for healthy living), the RD stated that all dietary documents containing patient information are put in the shredder and some in a wash bin where we put water and bleach to destroy the document; if they are not soiled they go in the shredder. RD further stated that all trash are discarded by dietary aides in the dumpster located outside in the back of the building.

During a record review of the facility's policy and procedures (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Patients'/Residents' Rights with a revision date of 4/2025 indicated, patient/resident medical records must not be left where others can see or have access to them.keep residents'/patients' records locked away and out of public areas.

The P&P also indicated paper records must be treated as though they contain Personal Health Information and are confidential.

056451 02/20/2026

Cheviot Hills Post Acute 3533 Motor Avenue Los Angeles, CA 90034

During a concurrent observation and interview on 2/19/2026, at 8:40 A.M., with Resident 60, in Resident 60's room, Resident 60's dignity curtain was seen with multiple scattered round/smeared brown spots. Resident 60 stated that the dignity curtain was dirty and that she has not seen the facility staff change the dignity curtain.

During a concurrent observation and interview on 2/19/2026, at 8:50 A.M., with Certified Nursing Assistant (CNA) 5, in Resident 60's room, Resident 60's dignity curtain was seen with multiple scattered round/smeared brown spots. CNA 5 stated that Resident 60's dignity curtain has some brown stuff on it, it was dirty.

During an interview on 2/19/2026, at 9:14 A.M., with House Keeping Account Manager (HKAM), HKAM stated that the facility process is that Residents rooms are deep cleaned once a month, per the monthly deep cleaning schedule, during that time, the resident's dignity curtains are changed and more frequently for dirty curtains. HKDM stated that dignity curtains integrity is checked daily by the housekeeping during regular daily cleaning and as needed.

The HKDM stated once housekeeping has deep cleaned a resident's room, the House Keeping Manager or Supervisor validates that the deep cleaning was done correctly using the facility's Quality Control Inspection (QCI) form. HKDM stated that the QCI form indicated that Resident 60's room was deep cleaned on 2/7/2026, however, there is no documented evidence on the form that Resident 60's dignity curtain was changed. HKDM stated that dignity curtains were not on QCI form and that they should be on it. HKDM stated that the dignity curtains should be on the form to ensure that they were changed/washed during room deep cleaning.

HKDM stated that residents' dignity curtains need to be washed/changed for sanitary purposes, for residents' dignity, have a clan environment and to prevent germs. A review of the Facility's policy and procedures (P&P), titled Quality of Life _Home like Environment, reviewed 10/20/2025, indicated that: Policy Statement: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.2.

The facility staff and management maximizes, to the extent possible, the characteristics of thefacility that reflect a personalized, homelike setting.

These characteristics include:a. clean, sanitary and orderly environment

056451 02/20/2026

Cheviot Hills Post Acute 3533 Motor Avenue Los Angeles, CA 90034

During a concurrent interview and record review, on 2/20/2026, at 8:02 A.M., with the Assistant Director of Nursing (ADON), Resident 72's Behold Policy and Notification, dated 8/7/2025 ND 11/5/2025, was reviewed.

The Behold Policy and Notification indicated person notified was resident 72'S family member (FM) via telephone.

The ADON stated that the Behold policy and Notification is given at the time of transfer and it is to notify the resident and their representatives that the resident will still have a bed in the facility, which is their primary home for 7 days on hold when they return.

The ADON stated for resident 72's transfer to GACH on 11/5/2025, the bed hold notification was done with resident 72's FM because resident 72 at the time could not go through the process of the bed hold in the current health state she was in.

The DON stated the bed hold notification was done via telephone with resident 72's FM.

During an interview, on 2/20/2026, at 10:10 A.M., with the Director of Nursing (DON), the DON stated upon admission, the facility's 7 (seven) days bed hold policy is discussed with the resident and the resident's representative.

The DON stated that the resident or the resident's representative signs the Behold Policy and Notification during admission that they have understood that Behold Policy and Notification information.

The DON stated upon a resident's transfer to GACH, a written 7 day bed hold notification is provided to the residents in the facility or their representatives via mail.

The DON stated that the resident and/or their representatives are aware that the resident can return to the facility and to the same bed with in 7 seven of discharge from GACH because the facility is the resident's home. A review of the facility's Policy &Procedures (P&P) titled Bed-Holds, Returns, Admissions, Discharges and Transfers with revision date 10/20/2025, indicated,Policy StatementResidents and/or representatives are informed (in writing) of the facility and state (ifapplicable) bed-hold policies.Policy Interpretation and Implementation1.

All residents/representatives are provided written information regarding the facilityand state bed-hold policies, which address holding or reserving a resident's bedduring periods of absence (hospitalization or therapeutic leave).

Residents,regardless of payer source, are provided written notice about these policies at leasttwice:a. notice 1: well in advance of any transfer (e.g., in the admission packet); andb. notice 2: at the time of transfer (or, if the transfer was an emergency, within 24hours).

056451 02/20/2026

Cheviot Hills Post Acute 3533 Motor Avenue Los Angeles, CA 90034

During record review, Resident 94's GACH Acute Care Physical Therapy Evaluation document dated 2/9/2026, indicated that Resident could ambulate (walk) without assistive device at bedside, required minimum contact guard assistance for sit to stand to sit and sit to stand and is able to ambulate up to 150 feet (ft-unit to measure distance) with standby assistance.

During a facility tour on 2/16/2026 at 8:40 a.m., 2 ounces (oz-unit of measurement) of orange liquid was observed inside a clear 8 oz drinking cup used by residents to drink fluids (water and juice) on top of the bathroom sink counter in Resident 94's bathroom.

During an interview on 2/16/2026 at 8:50 a.m., Certified Nurse Assistant (CNA) 6 stated the orange liquid in the Residents 8oz drinking cup was soap used to bathe residents. CNA6 stated he was unaware that bathing liquid soap had been poured into a cup that is used to provide drinks to residents and was left inside the Residents bathroom. CNA6 stated it is unsafe to pour soap inside a cup used by residents to drink fluids and to place it on top of the Resident bathroom sink where it can be easily reached and consumed by a resident.

During an interview on 2/20/2026 at 1:01 pm, the Director of Nursing (DON) stated pouring liquid bath soap inside residents drinking cup, placing the cup on top of the Resident bathroom sink counter, and leaving the cup unattended places the residents at risk of ingesting the liquid soap which can cause irritation of gastrointestinal (GI) lining, nausea, vomiting, diarrhea, cramps, abdominal pain, unnecessary hospitalization and even poor outcomes for the resident.

During record review, the facility's policy and procedures (P&P) titled Quality of care: Safety of Residents dated 10/20/2025, indicated Resident safety and supervision and assistance to prevent accidents are facility wide priorities.

Safety risks and environmental hazards are identified through employee training, employee monitoring and reporting and facility wide commitment to safety at all levels of the organization.

056451 02/20/2026

Cheviot Hills Post Acute 3533 Motor Avenue Los Angeles, CA 90034

During a concurrent observation and interview on 2/17/2026, at 9:19 A.M., with Resident 72, in Resident 72's room, a nebulizer machine was on Resident 72's nightstand and was connected to a tubing which was attached to an undated mask.

The mask was not stored in a bag. Resident 72 stated that she had chronic obstructive pulmonary disease (COPD - on going lung disease causing difficulty in breathing), uses the nebulizer as needed (PRN) and that the last time she used the nebulizer machine was yesterday, 2/16/2026.

During a concurrent observation and interview on 2/17/2026, at 9:33 A.M., with Licensed Vocations Nurse (LVN) 2, in Resident 72's room, a nebulizer machine was on Resident 72's nightstand, connected to a tubing and a mask attached to it without with no date and was not in a bag. LVN 2 stated that nebulizer tubing and mask need to be in a bag, covered with the resident's name on it and the date the tubing/mask was first opened. LVN 2 stated that the tubing and mask need to be bagged/dated to prevent infection control, to prevent the resident from getting respiratory viruses and getting sick. LVN 2 stated she will go ahead, disinfect the nebulizer machine, get a new tubing and mask for the nebulizer, put them in a bag and put a date on it.

During an interview with on 2/19/2026, at 10:01 A.M., with the Director of Nursing (DON), the DON stated that nebulizer tubing and mask needs to be stored in a bag with the resident's name and date on it.

The DON stated nebulizer tubing/masks need to be changed weekly and as needed.

The DON sated that, having a date on the tubing/mask is so that staff know when the tubing/mask needs to be changed.

The DON stated that having the nebulizer tubing and mask in the bag with the date is done so that germs may be prevented which may lead to an infection. A review of the facility's P&P titled Infection Prevention and Control Program, reviewed 10/20/2025, indicated that:PurposeAn infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.PolicyThe infection prevention and control program is developed to address the facility-specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment.

The program is reviewed annually and updated as necessary.11.

Prevention of Infection.(3) educating staff and ensuring that they adhere to proper techniques and procedures. A review of the facility's P&P titled Administering Medication through a small Volume (Handheld) Nebulizer, reviewed 10/2025, indicated that:PurposeThe purpose of this procedure is to safely and aseptically administer aerosolized particles ofmedication into the resident's airway.Steps in the Procedure26.

Rinse and disinfect the nebulizer equipment according to facility protocol.28.

When equipment is completely dry, store in a plastic bag with the resident's name and the date on it.29.

Change equipment and tubing every seven days, or according to facility protocol.

056451 02/20/2026

Cheviot Hills Post Acute 3533 Motor Avenue Los Angeles, CA 90034

During an interview on 2/19/2026, at 12:15 P.M., with the Director of Nursing (DON), the DON stated that, the facility process is that employee performance evaluations are done 90 days after employment, then annually and placed in the employee files.

The DON stated that performance evaluations are done to see if the employees are meeting the standards of the job descriptions, duties and responsibilities.

The DON stated if the performance evaluations are not done, the facility may not know if the employee is suitable to take care of the residents and possibly cause harm to the residents. A review of the facility's P&P tiled Performance Evaluations, reviewed 10/20/2025 indicated that: Policy StatementThe job performance of each employee shall be reviewed and evaluated at least annually.Policy Interpretation and Implementation1. A performance evaluation will be completed on each employee at the conclusion of his/her 90-day probationary period, and at least annually thereafter.

The performance evaluation meeting will occur at the same time as the employee's compensation review.

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.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

056451 02/20/2026

Cheviot Hills Post Acute 3533 Motor Avenue Los Angeles, CA 90034

During an interview on 2/20/2026 at 8:50 am, Restorative Nurse Assistant (RNA) 1, stated that she (RNA1)has consistently carried out the orders by apply hand roll splint to RUE 5X/WEEK, 4-8 hours as tolerated with skin check every day shift every Monday, Tuesday, Wednesday, Thursday, and Friday.

RNA1 stated she did not realize that there was a 2nd page to the Restorative Administration Record as her reason for failing to document.

During an interview on 2/20/2026 at 1:47 pm, the Director of Nursing (DON) stated documentation is a primary communication tool among the healthcare team and provides legal protections for practitioners. DON stated that, if a service is provided and not documented, it was not done. A review of facility's policy and procedures (P&P) titled Restorative Nursing Services dated 10/20/2025 indicated, Residents will receive restorative nursing services as needed to help promote optimal safety and independence. A review of facility's P&P titled Charting and Documentation dated, 10/20/2025 indicated, Services provided to the residents . shall be documented in the resident's medical record.

The medical record should facilitate communication between the interdisciplinary team.

056451 02/20/2026

Cheviot Hills Post Acute 3533 Motor Avenue Los Angeles, CA 90034

During an interview on 2/18/2026 at 2:45 p.m.

Registered Nurse (RN2) stated PICC lines are changed once a week and as needed if soiled. RN2 stated the importance of changing PICC lines is to ensure the Resident does not acquire an infection to assess the skin and ensure Resident is not allergic to the dressing. RN2 stated she was unaware Resident94's PICC line had not been changed for 8 days.

During an interview on 2/20/2026 at 12:57 p.m. the Director of Nursing (DON) stated PICC line changes are done every 7 days and as needed if soiled to prevent infection at the catheter site. DON stated the Resident can acquire infection that could result in sickness causing unnecessary hospitalization and extended antibiotic therapy.

A review of the facility's policy and procedures (P&P) titled, Peripheral and Midline IV Dressing Changes indicated, the purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections associated with contaminated, loosened, or soiled catheter-site dressings.

Guidelines: .Change the dressing .at list every 7 days for Transparent semi-permeable Membrane (TSM) dressing for all peripheral catheter sites.

A review of the facility's P&P titled Infection Prevention and Control Program dated 9/10/2024, subtitled Prevention of infection indicated, important facets of infection prevention include: Identifying possible infections or potential complications of existing infections Instituting measures to avoid complications or dissemination Following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC).

056451 02/20/2026

Cheviot Hills Post Acute 3533 Motor Avenue Los Angeles, CA 90034

During an interview on 02/17/2026 at 07:54 AM, with Certified Nurse Assistant (CNA) 3. CNA 3 stated she had checked on Resident 38 when she got report from the night shift CNA at change of shift. CNA 3 stated she was not sure how the call light got on the floor.

During an interview on 02/18/2026 at 3:24 PM Director of Nursing (DON) stated it is important for the residents to have the call lights available for them to call for assistance when they need help.

During a review of the facility's policy and procedures (P&P) titled, Call System Resident dated reviewed 10/20/2025, the P&P indicated, Policy Statement: Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation.Policy Interpretation and ImplementationEach resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities.