New Vista Post-acute Care Center

F-F658.

Findings:

During a review of Resident 4's Admission Record indicated Resident 4 was admitted to the facility on [DATE REDACTED] with diagnoses including dysphagia (difficulty swallowing food or liquid), chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide) and tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow direct access to the breathing tube).

During a review of Resident 4's Physician Orders, dated 5/23/2024, indicated a physician's orders scheduled at 9:00 a.m. for the following medications:

Multivitamin-Minerals (supplement) 1 tablet via gastrostomy (GT- a flexible tube surgically inserted through

the abdomen into the stomach for feeding, fluid, and medication administration)daily

Docusate Sodium (DSS-stool softener) 100 milligram (mg) via GT daily

Cranberry (supplement) 500 mg via GT daily

Famotidine (acid controller) 40 mg via GT twice a day

Amlodipine Besylate (medication to treat high blood pressure) 10 mg via GT daily, hold if systolic blood pressure is less than 100

Vitamin C (supplement) 500 mg via GT daily

Arginaid (protein powder) 1 packet via GT daily

During a review of Resident 4's Minimum Data Set (MDS - a comprehensive standardized assessment and care screening tool), dated 5/29/2024, indicated Resident 4's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making was severely impaired and dependent from staff for activities of daily living (ADLs- bed mobility, transfer, dressing, and toilet use).

During a review of Resident 4's Medication Administration Record (MAR), dated 7/25/2024, indicated scheduled medications at 9 a.m., were administered at 11:45 for the following medications:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 6 055473 Department of Health & Human Services Printed: 09/17/2025 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 055473 B. Wing 07/25/2024

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

New Vista Post-Acute Care Center 1516 Sawtelle Blvd. Los Angeles, CA 90025

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 0755 Multivitamin-Minerals 1 tablet via GT daily

Level of Harm - Minimal harm or Docusate Sodium 100 mg via GT daily potential for actual harm Cranberry 500 mg via GT daily Residents Affected - Few Famotidine 40 mg via GT twice a day

Amlodipine Besylate 10 mg via GT daily, hold if systolic blood pressure is less than 100

Vitamin C 500 mg via GT daily

Arginaid 1 packet via GT daily

During a concurrent medication administration observation and interview with the Licensed Vocational Nurse 1 (LVN1) on 7/25/2024 at 11:50 a.m., LVN1 administered the following medications scheduled for 9 a.m.:

Multivitamin-Minerals 1 tablet via GT daily

Docusate Sodium 100 mg via GT daily

Cranberry 500 mg via GT daily

Famotidine 40 mg via GT twice a day

Amlodipine Besylate 10 mg via GT daily, hold if systolic blood pressure is less than 100

Vitamin C 500 mg via GT daily

Arginaid 1 packet via GT daily

During a concurrent interview, LVN1 stated medication administration should be done an hour before and an hour after the scheduled time (9 a.m.). LVN1 stated it was okay to give the medication late since LVN1 was busy that morning and there was no other nurse that could assist LVN1 administer medications.

During an interview with Registered Nurse 1 (RN1) on 7/25/2024 at 12:15 p.m., RN1 stated medications should be administered an hour before or an hour after scheduled time. RN1 also stated that although unacceptable, LVN1 was still able to give the morning scheduled medications even though LVN1 was busy

in the morning. RN1 also stated LVN1 was the only one who could administer the medications to Resident 4.

During an interview with the Director of Nursing (DON) on 7/25/2024 at 1:37 p.m., the DON stated, per nursing standard of practice, it was unacceptable to give a scheduled medications for 9 a.m. at around 12 p. m. The DON also stated that the nurse (LVN1) was supposed to notify the physician for any changes in the schedule medication administration.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 6 055473 Department of Health & Human Services Printed: 09/17/2025 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 055473 B. Wing 07/25/2024

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

New Vista Post-Acute Care Center 1516 Sawtelle Blvd. Los Angeles, CA 90025

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 0755 A review of the facility's policy and procedures (P&P), titled, Medication Administration, reviewed on 7/12/2024, indicated, facility has a sufficient staff to allow administering or medications without unnecessary Level of Harm - Minimal harm or interruptions. Medications are administered within 60 minutes of scheduled time and according to the potential for actual harm established medication administration schedule for the facility.

Residents Affected - Few A review of the facility's job description (JD), titled, Licensed Vocational Nurse (LVN), undated, JD indicated,

an LVN will practice professional skills by always adhering to the professional standards of the facility and

the profession. JD also indicated that an LVN will be able to knowledgeably and safely provide all medication as ordered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 6 055473

F-F755.

Findings:

During a review of Resident 4's Admission Record indicated Resident 4 was admitted to the facility on [DATE REDACTED] with diagnoses including dysphagia (difficulty swallowing food or liquid), chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide) and tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow direct access to the breathing tube).

During a review of Resident 4's Physician Orders, dated 5/23/2024, indicated a physician's orders scheduled at 9:00 a.m. for the following medications:

Multivitamin-Minerals (supplement) 1 tablet via gastrostomy (GT- a flexible tube surgically inserted through

the abdomen into the stomach for feeding, fluid, and medication administration)daily

Docusate Sodium (DSS-stool softener) 100 milligram (mg) via GT daily

Cranberry (supplement) 500 mg via GT daily

Famotidine (acid controller) 40 mg via GT twice a day

Amlodipine Besylate (medication to treat high blood pressure) 10 mg via GT daily, hold if systolic blood pressure is less than 100

Vitamin C (supplement) 500 mg via GT daily

Arginaid (protein powder) 1 packet via GT daily

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 6 055473 Department of Health & Human Services Printed: 09/17/2025 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 055473 B. Wing 07/25/2024

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

New Vista Post-Acute Care Center 1516 Sawtelle Blvd. Los Angeles, CA 90025

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 0658 During a review of Resident 4's Minimum Data Set (MDS - a comprehensive standardized assessment and care screening tool), dated 5/29/2024, indicated Resident 4's cognitive (mental action or process of acquiring Level of Harm - Minimal harm or knowledge and understanding) skills for daily decision-making was severely impaired and dependent from potential for actual harm staff for activities of daily living (ADLs- bed mobility, transfer, dressing, and toilet use).

Residents Affected - Few During a review of Resident 4's Medication Administration Record (MAR), dated 7/25/2024, indicated scheduled medications at 9 a.m., were administered at 11:45 for the following medications:

Multivitamin-Minerals 1 tablet via GT daily

Docusate Sodium 100 mg via GT daily

Cranberry 500 mg via GT daily

Famotidine 40 mg via GT twice a day

Amlodipine Besylate 10 mg via GT daily, hold if systolic blood pressure is less than 100

Vitamin C 500 mg via GT daily

Arginaid 1 packet via GT daily

During a concurrent medication administration observation and interview with the Licensed Vocational Nurse 1 (LVN1) on 7/25/2024 at 11:50 a.m., LVN1 administered the following medications scheduled for 9 a.m.:

Multivitamin-Minerals 1 tablet via GT daily

Docusate Sodium 100 mg via GT daily

Cranberry 500 mg via GT daily

Famotidine 40 mg via GT twice a day

Amlodipine Besylate 10 mg via GT daily, hold if systolic blood pressure is less than 100

Vitamin C 500 mg via GT daily

Arginaid 1 packet via GT daily

During a concurrent interview, LVN1 stated medication administration should be done an hour before and an hour after the scheduled time (9 a.m.). LVN1 stated it was okay to give the medication late since LVN1 was busy that morning and there was no other nurse that could assist LVN1 administer medications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 6 055473 Department of Health & Human Services Printed: 09/17/2025 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 055473 B. Wing 07/25/2024

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

New Vista Post-Acute Care Center 1516 Sawtelle Blvd. Los Angeles, CA 90025

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 0658 During an interview with Registered Nurse 1 (RN1) on 7/25/2024 at 12:15 p.m., RN1 stated medications should be administered an hour before or an hour after scheduled time. RN1 also stated that although Level of Harm - Minimal harm or unacceptable, LVN1 was still able to give the morning scheduled medications even though LVN1 was busy potential for actual harm in the morning. RN1 also stated LVN1 was the only one who could administer the medications to Resident 4.

Residents Affected - Few During an interview with the Director of Nursing (DON) on 7/25/2024 at 1:37 p.m., the DON stated, per nursing standard of practice, it was unacceptable to give a scheduled medications for 9 a.m. at around 12 p. m. The DON also stated that the nurse (LVN1) was supposed to notify the physician for any changes in the schedule medication administration.

A review of the facility's policy and procedures (P&P), titled, Medication Administration, reviewed on 7/12/2024, indicated, facility has a sufficient staff to allow administering or medications without unnecessary interruptions. Medications are administered within 60 minutes of scheduled time and according to the established medication administration schedule for the facility.

A review of the facility's job description (JD), titled, Licensed Vocational Nurse (LVN), undated, JD indicated,

an LVN will practice professional skills by always adhering to the professional standards of the facility and

the profession. JD also indicated that an LVN will be able to knowledgeably and safely provide all medication as ordered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 6 055473 Department of Health & Human Services Printed: 09/17/2025 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 055473 B. Wing 07/25/2024

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

New Vista Post-Acute Care Center 1516 Sawtelle Blvd. Los Angeles, CA 90025

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 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43261

Residents Affected - Few Based on observation, interview, and record review, the facility failed to timely administer medications per facility policy to one of three sampled resident (Resident 4).

This failure had the potential to result in medication ineffectiveness and risk for unsafe, and improper medication administration use.

Cross Reference