The Rehabilitation Center On Pico

F-F759

Findings:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 55 056377 Department of Health & Human Services Printed: 09/07/2025 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 056377 B. Wing 02/27/2025

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

The Rehabilitation Center on Pico 3233 W. Pico Boulevard Los Angeles, CA 90019

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 0760 a. A review of the Admission Record indicated Resident 50 was admitted to the facility on [DATE REDACTED] with diagnoses including hemiplegia (a severe or complete loss of strength or paralysis on one side of the body) Level of Harm - Immediate and hemiparesis (a mild or partial weakness or loss of strength on one side of the body) following cerebral jeopardy to resident health or infarction (a stroke that occurs when blood flow to the brain is blocked) affecting left non-dominant side, safety hypertension (high blood pressure), cardiomegaly (a condition where the heart is larger than normal), and atrial fibrillation (AF, abnormal heartbeat). Residents Affected - Many

During a review of Resident 50's Minimum Data Set (MDS - a resident assessment tool) dated 9/26/24, the MDS indicated Resident 50's cognitive skills (mental activities including thinking, reasoning, understanding, learning, and remembering) for daily decision-making was moderately impaired. Resident 50's MDS indicated the resident required setup for eating and oral hygiene, required substantial assistance for personal hygiene and was dependent on staff physical assistance.

During a review of Resident 50's History and physical (H&P) dated 2/29/2024, the H&P indicated Resident 50 had the capacity to understand and make decisions.

During a review of Resident 50's Order Summary Report, the Order Summary Report indicated Resident 50's orders included:

-Apixaban (Eliquis, an anticoagulant, a blood thinner) 5 (five) milligrams (mg - unit of measure of weight) give one tablet by mouth every 12 hours, scheduled at 9 a.m., and 9 p.m., for AF, order date 4/26/2023.

-Amlodipine (Norvasc, a medication used to treat high blood pressure) 5 mg, give one tablet by mouth one time a day, scheduled at 9 a.m., for hypertension, hold if systolic blood pressure (SBP, when the heart beats, top number) is less than 110 millimeters of mercury [mm Hg]), (mmHg - unit of measure), order date 8/28/2024.

-Aspirin Enteric Coated (EC) 81 mg, give one tablet by mouth one time a day, scheduled at 9 a.m., for myocardial infarction (MI, also known as a heart attack, occurs when blood flow to the heart is blocked) prophylactically (PPX, measures designed to preserve health), order date 6/17/2020.

During a review of Resident 50's, Care Plans, the care plans for Resident 50 indicated the following:

-Black Box Warning (is a serious warning given by the Food and Drug Administration [FDA] for drugs or drug classes that may cause serious harm or death) for use of Apixaban (Eliquis), dated 3/27/2020. Resident 50's care plan goal indicated; the resident will not experience side effects/ interactions with the use of Apixaban (Eliquis).

-Anticoagulant therapy, Apixaban for atrial fibrillation, at risk for active bleeding, revised 2/6/2025. Resident 50's care plan intervention indicated give Apixaban 5 mg by mouth every 12 hours for AF. Resident/family/caregiver teaching to include the following: take/give medication at the same time each day.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 55 056377 Department of Health & Human Services Printed: 09/07/2025 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 056377 B. Wing 02/27/2025

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

The Rehabilitation Center on Pico 3233 W. Pico Boulevard Los Angeles, CA 90019

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 0760 -Hypertension (HTN) related to lifestyle and stroke, dated 3/27/2020. The interventions included instructions to give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension (a Level of Harm - Immediate sudden drop in blood pressure when standing) and increased heart rate (tachycardia) and effectiveness. jeopardy to resident health or safety -Risk for repeat Cardiovascular Accident (CVA) as resident had a CVA prior to admission, date revised 2/6/2025, and goal indicated to minimize risk with interventions. Interventions indicated, administer Residents Affected - Many medication(s) as ordered.

-Risk for adverse reaction related to polypharmacy (the simultaneous use of multiple drugs by a single patient, for one or more conditions), revision date 2/6/2025. Resident 50's care plan interventions included to

review resident's medications with MD/Consultant pharmacist for proper dosing, timing and frequency of administrations.

During a concurrent observation and interview on 2/25/2025 at 10:17 a.m., with a Licensed Vocational Nurse (LVN) 3 on Station 2 at Medication Cart (MedCart) 2, LVN 3 stated she was preparing the morning medications for Resident 50 that was scheduled for 9 a.m. During a medication pass observation on 2/25/2025 at 10:20 a.m., with LVN 3, LVN 3 prepared and administered Resident 50's morning medications, scheduled for 9 a.m., administration that included Apixaban 5 mg, one tablet, Amlodipine 5 mg, one tablet, and Aspirin Enteric Coated (EC) 81 mg, one tablet.

During an interview on 2/25/2025 at 10:32 a.m., Resident 50 stated she usually gets her medications late, but she knew the nurses were very busy.

During an interview on 2/25/2025 at 10:38 a.m., LVN 3 stated she had 17 more residents to administer morning medications to that were scheduled for 9 a.m LVN 3 stated the supervisor and Director of Nursing (DON) was made aware of the heavy load, which included four of her 32 residents received medications through a gastrostomy tube (GT - a tube inserted through the belly that brings nutrition, fluids, and medications directly to the stomach), which takes more time and that she was not able to pass medications to all of residents on time.

During an earlier interview on 2/25/2025 at 10:11 a.m., with LVN 1, on Station 2, at MedCart 3, LVN 1 stated

he had 12 more residents to pass medications scheduled for 9 a.m., out of a total of 27 residents, and usually finished passing morning medications each day around 11:30 a.m. LVN 1 stated he notified a Registered Nurse Supervisor. LVN 1 stated, It can be overwhelming, especially when you are trying to give

the best care, not rush residents, and not make mistakes.

During an interview on 2/25/2025 at 1:32 p.m., the DON stated licensed nurses should administer medications within an hour of the scheduled administration time or up to an hour after the scheduled administration time. The DON stated the resident's physician must be notified if resident's medications would be administered outside of the time frame and then following the physician's instructions, if it was okay to administer the medication.

During a record review of Resident 50's Medication Administration Audit Report, Resident 50's Medication Audit Report was reviewed between 2/1 to 2/25/2025. The Medication Administration Audit Report indicated Resident 50 was administered apixaban, amlodipine, and aspirin late and for apixaban less than 12 hours from the next scheduled dose as follow on:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 55 056377 Department of Health & Human Services Printed: 09/07/2025 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 056377 B. Wing 02/27/2025

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

The Rehabilitation Center on Pico 3233 W. Pico Boulevard Los Angeles, CA 90019

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 0760 -2/2/2025 apixaban 5 mg, amlodipine, and aspirin scheduled for administration at 9 a.m., was documented administered at 3:09 p.m. (six hours and nine minutes late). Level of Harm - Immediate jeopardy to resident health or -2/2/2025 apixaban 5 mg scheduled for administration at 9 p.m., was administered at 8:33 p.m., five hours safety and 24 minutes after the last dose was given at 3:09 p.m., instead of the ordered 12 hours between doses.

Residents Affected - Many -2/4/2025 apixaban 5 mg, amlodipine, and aspirin scheduled for administration at 9 a.m., was documented administered at 10:57 a.m. (one hour and 57 minutes late).

-2/8/2025 apixaban 5 mg, amlodipine, and aspirin scheduled for administration at 9 a.m., was documented administered at 10:35 a.m. (one hour and 35 minutes late).

-2/9/2025 apixaban 5 mg, amlodipine, and aspirin scheduled for administration at 9 a.m., was documented administered at 1:55 p.m. (four hours and 55 minutes late).

-2/9/2025 apixaban 5 mg scheduled for administration at 9 p.m., was administered at 8:17 p.m., six hours and 22 minutes after the last dose was given at 1:55 p.m., instead of the ordered 12 hours between doses.

-2/12/2025 apixaban 5 mg, amlodipine, and aspirin scheduled for administration at 9 a.m., was documented administered at 10:58 a.m. (one hour and 58 minutes late).

-2/13/2025 apixaban 5 mg, amlodipine, and aspirin scheduled for administration at 9 a.m., was documented administered at 11:08 p.m. (two hours and eight minute late).

-2/16/2025 apixaban 5 mg, amlodipine, and aspirin scheduled for administration at 9 a.m., was documented administered at 1:02 p.m. (four hours and two minutes late).

-2/16/2025 apixaban 5 mg scheduled for administration at 9 p.m., was administered at 8:43 p.m., seven hours and 41 minutes after the last dose was given at 1:02 p.m., instead of the ordered 12 hours between doses.

-2/21/2025 apixaban, amlodipine, and aspirin scheduled for administration at 9 a.m., was documented administered at 10:33 a.m. (one hour and 33 minutes late).

-2/22/2025 apixaban 5 mg scheduled for administration at 9 a.m., was documented administered at 6:03 p. m. (nine hours and three minutes late).

-2/22/2025 apixaban 5 mg scheduled for administration at 9 p.m., was documented administered at 8:51 p. m. two hours and 48 minutes after the last dose was given at 6:03 p.m., instead of the ordered 12 hours between doses.

-2/23/2025 apixaban, amlodipine, and aspirin scheduled for administration at 9 a.m., was documented administered at 11:10 a.m. (two hours and 10 minutes late)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 55 056377 Department of Health & Human Services Printed: 09/07/2025 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 056377 B. Wing 02/27/2025

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

The Rehabilitation Center on Pico 3233 W. Pico Boulevard Los Angeles, CA 90019

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 0760 -2/22/2025 apixaban 5 mg scheduled for administration at 9 p.m., was documented administered at 9:22 p.m. , ten hours and 22 minutes after the last dose was given at 11:10 a.m., instead of the ordered 12 hours Level of Harm - Immediate between doses. jeopardy to resident health or safety b. A review of Resident 10's Admission Record indicated the resident was admitted to the facility on [DATE REDACTED] with diagnoses including Type II diabetes (DM, a condition that occurs when the body does not use insulin Residents Affected - Many properly, leading to high blood sugar levels), hypertension (high blood pressure), myocardial infarction (MI), and AF.

During a review of Resident 10's, MDS dated [DATE REDACTED], the MDS indicated Resident 10's cognitive skills for daily decision-making was moderately impaired.

During a review of Resident 10's Order Summary Report, the Order Summary Report indicated Resident 10 had orders for:

-Eliquis 2.5 mg, to give one tablet by mouth two times a day scheduled at 9 a.m. and 5 p.m., for AF, with an order date of 3/27/2024.

-Eliquis: Monitor for signs and symptoms of bleeding (abnormal or unexplained bruising, petechiae (tiny spots of bleeding under the skin), internal bleeding, nosebleeds, bleeding gums, abnormal bleeding) by (+) Yes or (-) No. Notify MD if (+) every shift (Day shift, Evening Shift, and Night Shift), order date 11/10/2023.

-Metformin 500 mg, one tablet by mouth four times a day for DM, give with food, order date 11/2/2023

During a review of Resident 10's, Care Plans, the care plans indicated:

-Resident 10 had High Risk for Bleeding, Bruising, and/or Skin Discoloration related to anticoagulant therapy, Eliquis, dated 12/1/2022. Resident 10's care plan goal indicated, the resident will remain free of abnormal bleeding or bruising, and the care plan intervention indicated, administer medications as ordered and monitor for side effects. Observe / record / report to MD as needed, abnormal or unexplained bruising.

-Resident 10 had a Black Box Warning for use of Metformin (Glucophage) for diabetes mellitus (DM), revised 2/8/2025. Resident 10's care plan goal indicated the resident will not experience side effect/ interactions with

the use of Metformin, and the care plan interventions included, Black Box Warning, post marketing cases of metformin-associated lactic acidosis (lactic acid build up in the bloodstream) have resulted in death, hypothermia (body loses heat faster than it can produce heat), hypotension (low blood pressure), and resistant bradyarrhythmia (an irregular heartbeat that's slower than normal). The onset of metformin-associated lactic acidosis is often subtle, accompanied only by myalgias (muscle pain), respiratory distress (difficulty to breath), somnolence (drowsiness), and abdominal pain.

During a review of Resident 10's Nursing Progress Notes dated 2/24/2025 at 8:46 a.m., Resident 10's progress notes indicated, On monitoring for discoloration to right wrist. Resident still noted with discoloration

in affected wrist.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 55 056377 Department of Health & Human Services Printed: 09/07/2025 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 056377 B. Wing 02/27/2025

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

The Rehabilitation Center on Pico 3233 W. Pico Boulevard Los Angeles, CA 90019

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 0760 During a record review of Resident 10's Medication Administration Audit Report, Resident 10's Medication Audit Report was reviewed between 2/1/2025 to 2/25/2025, the Medication Administration Audit Report Level of Harm - Immediate indicated resident was administered apixaban less than 8 hours from the next scheduled dose as follow on: jeopardy to resident health or safety -2/17/2025 apixaban 2.5 mg, scheduled for administration at 9 a.m., was documented administered at 11:12 a.m. (two hours and 12 minutes late). Residents Affected - Many -2/24/2025 apixaban 2.5 mg, scheduled for administration at 9 a.m., was documented administered at 2:29 p. m. (five hours and 29 minutes late).

-2/24/2025 apixaban 2.5 mg scheduled for administration at 5 p.m., was administered at 5:17 p.m., two hours and 48 minutes after the last dose was given at 2:29 p.m., instead of the ordered eight hours between doses.

-2/25/2025 apixaban 2.5 mg, scheduled for administration at 9 a.m., was documented administered at 1:34 p. m. (four hours and 34 minutes late).

-2/17/2025 metformin 500 mg, scheduled for administration at 7:30 a.m., to be given with food was documented administered at 11:10 a.m. (over three hours late).

-2/18/2025 metformin 500 mg, scheduled for administration at 7:30 a.m., to be given with food was documented administered at 10:09 a.m. (over two hours late).

-2/17/2025 metformin 500 mg, scheduled for administration at 7:30 a.m., to be given with food was documented administered at 9:57 a.m. (two hours late).

-2/20/2025 metformin, scheduled for administration at 5:30 p.m., to be given with food was documented administered at 7:39 p.m. (two hours late).

-2/24/2025 metformin, scheduled for administration at 7:30 a.m., to be given with food was documented administered at 2:28 p.m. (almost seven hours late).

-2/17/2025 metformin, scheduled for administration at 5:30 p.m., to be given with food was documented administered at 5:17 p.m. (less than three hours since last administration of 2:38 p.m.).

c. During a review of Resident 54's Admission Record, the Admission Record indicated Resident 54 was admitted to the facility on [DATE REDACTED] with diagnoses that included repeated falls, cardiomegaly, hypertension, and atrial flutter (a condition in which the heart's upper chambers [atria] beat too quickly)

During a review of Resident 54's, MDS dated [DATE REDACTED], the MDS indicated Resident 54's cognitive skills for daily decision-making was severely impaired.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 55 056377 Department of Health & Human Services Printed: 09/07/2025 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 056377 B. Wing 02/27/2025

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

The Rehabilitation Center on Pico 3233 W. Pico Boulevard Los Angeles, CA 90019

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 0760 A review of Resident 54's H&P dated 6/22/2024 indicated, She has been in ED (emergency department) three times in three days following falls at her SNF (a previous skilled nursing facility). First visit on 6/15/2024 Level of Harm - Immediate after a witnessed fall while getting up from bed and tempted to use her walker and fell . Resident 54's H&P jeopardy to resident health or indicated the resident had persistent atrial fibrillation and was on anticoagulant therapy, Fall Risk safety Precautions, and did not have medical decision making capacity.

Residents Affected - Many During a review of Resident 54's Order Summary Report for February 2025, the Order Summary Report indicated Resident 54 had an order for Eliquis 2.5 mg, to give one tablet by mouth two times a day scheduled at 9 a.m., and 5 p.m., for AF / atrial flutter.

During a review of Resident 54's Care Plans revised 1/5/2025, the care plans indicated Resident 54:

-was at risk for falls related to gait/balance problems, at risk for fall due to history of repeated falls prior to admission to facility. The most recent fall was on 12/25/2024.

-has Black Box Warning for use of apixaban (Eliquis): atrial fibrillation, resident's care plan goal revised 10/14/2024 indicated Resident 54 will not experience side effects/interactions with the use of apixaban (Eliquis).

During a record review of Resident 54's Medication Administration Audit Report, Resident 54's Medication Audit Report was reviewed between 2/1/2025 to 2/25/2025, the Medication Administration Audit Report indicated resident was administered apixaban less than 8 hours from the next scheduled dose as follows on:

-2/17/2025 apixaban 2.5 mg, scheduled for administration at 9 a.m., was documented administered at 11:48 a.m. (two hours and 48 minutes late).

-2/17/2025 apixaban 2.5 mg scheduled for administration at 5 p.m., was administered at 5:42 p.m., five hours and 54 minutes after the last dose was given at 11:48 a.m., instead of the ordered eight hours between doses.

-2/18/2025 apixaban 2.5 mg, scheduled for administration at 9 a.m., was documented administered at 11:40 a.m. (two hours and 40 minutes late).

-2/18/2025 apixaban 2.5 mg scheduled for administration at 5 p.m., was administered at 5:14 p.m., five hours and 54 minutes after the last dose was given at 11:40 a.m., instead of the ordered eight hours between doses.

-2/20/2025 apixaban 2.5 mg, scheduled for administration at 9 a.m., was documented administered at 12:03 p.m. (three hours and three minutes late).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 55 056377 Department of Health & Human Services Printed: 09/07/2025 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 056377 B. Wing 02/27/2025

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

The Rehabilitation Center on Pico 3233 W. Pico Boulevard Los Angeles, CA 90019

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 0760 During an interview on 2/25/2025 at 3:06 PM with DON, the DON provided a list of 23 residents which included Residents 8, 10, 11, 32, 54, 66, 95, 99. Eleven of the 23 residents were on Station 2, MedCart 2 Level of Harm - Immediate and 12 of the 23 residents were on Station 2, MedCart 3, that were administered morning medications jeopardy to resident health or scheduled for 9 a.m., over 60 minutes pass the scheduled administration time, close to the next scheduled safety dose, and/ or not in accordance with the physician's orders between 2/17/2025 - 2/25/2025. The DON stated there was no documentation that the physician was called prior to LVN 1 and LVN 2 administering Residents Affected - Many medications late to residents on Station 2 MedCart 2, and to residents on Station 2 MedCart 3 on 2/25/2025.

The DON stated the physician should have been called before administering medications late to residents and they were working to notify the physicians now.

d. During a review of Resident 1's Admission Record indicated the resident was admitted to the facility on [DATE REDACTED] and readmitted [DATE REDACTED] with diagnoses including seizures (a sudden, uncontrolled burst of electrical activity in the brain that can cause temporary changes in behavior, movement, sensation, or awareness), cerebral palsy (a brain disorder that affects a person's ability to move and maintain balance and posture), and cerebral infarction (stroke, death of brain tissue caused by a lack of blood flow) due to occlusion or stenosis of right middle cerebral artery (a narrowing or blockage of the blood vessel that supplies blood to

the brain).

During a review of Resident 1's, MDS dated [DATE REDACTED], the MDS indicated Resident 1's cognitive skills (mental activities including thinking, reasoning, understanding, learning, and remembering) for daily decision-making was intact. Resident 1's MDS indicated the resident required set up for eating, moderate assistance for oral hygiene and was dependent on staff for physical assistance.

During a review of Resident 1's, H&P dated 1/29/23 the H&P indicated Resident 1 had the capacity to understand and make decisions.

During a review of Resident 1's Order Summary Report, the Order Summary Report indicated Resident 1 had an order for Depakote (valproic acid) Solution 250 milligrams (mg - unit of measure of weight) per 5 (five) milliliters (ml - unit of measure of volume) 250 mg/5 ml, to give 5 ml by mouth three times a day, scheduled at 9 a.m., 1 p.m., and 5 p.m., for seizure, order date 2/23/2023.

During a review of Resident 1's, Care Plan revised 2/7/2025, the care plan indicated Resident 1 had a Black Box Warning (a serious warning given by the Food and Drug Administration (FDA) for drugs or drug classes that may cause serious harm or death) for use of Depakote (valproic acid), indication for seizures, care plan goal indicated the resident will not experience side effects/interactions (when one drug alters the effectiveness of another drug) with the use of Depakote. Resident 1's care plan intervention indicated, Black Box Warning .monitor resident closely . Hepatic failure resulting in fatalities has occurred in patients receiving valproate .Severe or fatal hepatotoxicity may be preceded by nonspecific symptoms such as malaise (a general feeling of being unwell), weakness, lethargy (lack of energy), facial edema (swelling), and vomiting. In patients with epilepsy (a neurological condition that causes unprovoked, recurrent seizures [is a sudden rush of abnormal electrical activity in your brain]), a loss of seizure control may also occur.

During a record review on 2/27/25 at 1:30 p.m., with the Director of Nursing (DON), Resident 1's Medication Administration Audit Report was reviewed for 2/17/2025 to 2/26/2025, the Medication Administration Audit Report indicated the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 55 056377 Department of Health & Human Services Printed: 09/07/2025 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 056377 B. Wing 02/27/2025

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

The Rehabilitation Center on Pico 3233 W. Pico Boulevard Los Angeles, CA 90019

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 0760 -Resident 1's scheduled 9 a.m. dose of valproic acid was given at 1:37 p.m., on 2/20/2025, which was four hours and 37 minutes later than scheduled and dose. The valproic acid ordered for 1 p.m. was given at 2:16 Level of Harm - Immediate p.m. on 2/20/2025, which was 39 minutes after the last dose was given at 1:37 p.m. jeopardy to resident health or safety -Resident 1's scheduled 9 a.m. dose of valproic acid was given at 10:58 a.m., on 2/22/2025, which was one hour and 58 minutes later than scheduled dose and the valproic acid ordered for 1 p.m. was given at 12:12 p. Residents Affected - Many m. on 2/22/2025, which was one hour and 14 minutes after the last dose was given at 10:58 a.m.

-Resident 1's scheduled 9 a.m. dose of valproic acid was given at 11:21 a.m., on 2/23/2025, which was two hours and 21 minutes later than scheduled and the valproic acid ordered for 1 p.m. was given at 12:54 p.m.

on 2/23/2025, which was one hour and 33 minutes after the last dose was given at 11:21 a.m.

-Resident 1's scheduled 9 a.m. dose of valproic acid was given at 12:33 p.m., on 2/25/2025, which was three hours and 33 minutes later than scheduled and the valproic acid ordered for 1 p.m. was given at 2:28 p.m.

on 2/25/2025, which was one hour and 55 minutes after the last dose was given at 12:33 p.m.

During an interview on 2/27/2025 at 1:38 p.m., the DON stated giving a seizure medication 40 minutes after

the first dose or close to the next scheduled dose was not acceptable. The DON stated this would be considered double dosing and could cause Resident 1 to experience adverse reactions (unwanted or harmful effect that can occur when taking a drug or undergoing a medical procedure) and could cause Resident 1 to reach toxic levels of the valproic acid, could trigger a seizure or lead the resident becoming hospitalized for uncontrolled seizures or death.

During a review of the facility's Policy and Procedure (P&P) titled, Medication Administration - General Guidelines, dated 10/2012, the P&P indicated the facility had sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. Medications were administered in accordance with written orders of the prescriber. Medications were administered within (60 minutes) of scheduled time, except before or after meal orders, which are administered (based on mealtimes).

e. During a review of Resident 37's Admission Record, the Admission Record indicated Resident 37 was admitted to the facility on [DATE REDACTED] and readmitted [DATE REDACTED] with diagnoses including seizures and traumatic subdural hemorrhage (a brain injury that occurs when blood builds up between the brain and the skull) with loss of consciousness of unspecified duration

During a review of Resident 37's MDS dated [DATE REDACTED], the MDS indicated Resident 37's cognitive skills for daily decision-making was moderately impaired. Resident 37's MDS indicated the resident required set up for eating and was dependent on staff for physical assistance with oral hygiene, bathing, and dressing,

During a review of Resident 37's, H&P dated 3/31/22, the H&P indicated Resident 37 can make needs known but cannot make medical decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 55 056377 Department of Health & Human Services Printed: 09/07/2025 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 056377 B. Wing 02/27/2025

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

The Rehabilitation Center on Pico 3233 W. Pico Boulevard Los Angeles, CA 90019

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 0760 During a review of Resident 37's Order Summary Report, the Order Summary Report for February 2025 indicated Resident 37 had an order for Keppra (levetiracetam) 500 mg, to give one tablet by mouth two times Level of Harm - Immediate a day, scheduled at 9 a.m. and 5 p.m., for seizures. jeopardy to resident health or safety During a review of Resident 37's, Care Plan revised 2/7/2025, the care plan indicated Resident 37 had a seizure disorder and the care plan intervention indicated to give seizure medication as ordered by doctor, to Residents Affected - Many monitor and document side effects and effectiveness.

During a record review, Resident 37's Medication Administration Audit Report was reviewed for 2/17/2025 to 2/26/2025, the Medication Administration Audit Report indicated the following:

-Resident 37's scheduled 9 a.m. dose of levetiracetam was given at 2:12 p.m., on 2/20/2025, which was five hours and 12 minutes later than scheduled and the levetiracetam ordered for 5 p.m. was given at 5:47 p.m.

on 2/20/2025, which was three hours 35 minutes after the last dose was given at 2:12 p.m.

-Resident 37's scheduled 9 a.m. dose of levetiracetam was given at 11:01 a.m., on 2/22/2025, two hours later than scheduled.

-Resident 37's scheduled 9 a.m. dose of levetiracetam was given at 11:24 a.m., on 2/23/2025, two hours and 24 minutes later than scheduled.

-Resident 37's scheduled 9 a.m. dose of levetiracetam was given at 12:11 p.m., on 2/24/2025, over three hours later than scheduled.

-Resident 37's scheduled 5 p.m. dose of levetiracetam was given at 10:54 p.m., on 2/24/2025, almost six hours later than scheduled.

-Resident 37's scheduled 9 a.m. dose of levetiracetam was given at 12:06 p.m., on 2/25/2025, which was three hours and six minutes later than scheduled and the levetiracetam ordered for 5 p.m. was given at 5:29 p.m. on 2/20/2025, which was four hours 23 minutes after the last dose was given at 12:06 p.m.

During an interview on 2/26/2025 at 1:37 p.m., with the facility's Pharmacist Consultant (PC) stated the facility was supposed to have a process in place to have another nurse help to ensure medication administration did not run into the noon or next medication administration time if residents had medications scheduled for two or three times a day. The PC stated he suggested to the facility's Assistant Director of Nursing (ADON) and the DON several months ago, having another nurse to assist with medication pass to prevent late medication administration. The PC stated when medications were administered over three hours late, that was not acceptable practice. The PC stated it was important to give apixaban as ordered because of the pharmacokinetics (the movement of drug into, though, and out of the body) of the medication to maintain therapeutic effects (the response(s) after a treatment of any kind, the results of which were judged to be useful or favorable).

The PC stat

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 55 056377 Department of Health & Human Services Printed: 09/07/2025 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 056377 B. Wing 02/27/2025

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

The Rehabilitation Center on Pico 3233 W. Pico Boulevard Los Angeles, CA 90019

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 0802 Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Level of Harm - Minimal harm or potential for actual harm 47441

Residents Affected - Few Based on observation, interview and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when staff were:

-Unable to verbalize the cooling process of food.

-Unable to verbalize and demonstrate the correct process of checking quaternary ammonium compound (QUAT, a chemical that disinfect) sanitizer concentration testing for the red buckets and three compartment sink's (sink for dishwashing that have wash, rinse and sanitize compartments) use.

These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 90 of 92 medically compromised residents who received food and ice from the kitchen.

Findings:

a. During an observation on 2/24/2025 at 9:33 a.m. in the walk-in refrigerator, observed cooked turkey sausage in a container with prepared date of 2/23/2025 and with the use by date of 2/26/2025. Observed breaded chicken labeled with prepared date 2/23/2025 and with the use by date of 2/26/2025.

During a concurrent interview and record review on 2/25/2025 at 10:18 a.m. with the Dietary Supervisor (DS), Cooling Monitoring Form dated 2/2025 was reviewed. The Cooling Monitoring Form indicated, there were no breaded chicken and sausage record times and temperatures monitoring entry on 2/23/2025. The DS stated there was no entry for sausage and breaded chicken on 2/23/2025 and staff were to monitor time and temperature for the sausage and breaded chicken. The DS stated it was important to cool down food safely to prevent bacterial growth in food. The DS stated without proper cool down of food, residents could get food poisoning and foodborne illnesses as a potential outcome.

During an interview on 2/25/2025 at 10:25 a.m., [NAME] 1 stated the temperature of cooked food must be above 160 degrees Fahrenheit ([ F], a degree of temperature) and it should go down to 150 F to 140 F after two (2) hours then go down further to 70 F after three (3) to four (4) hours. [NAME] 1 stated properly cooled foods should be at a temperature of 70 F and below.

During an interview on 2/25/2025 at 10:29 a.m., the DS stated cooling of food must be below 60 F within 2 hours and cool down further within 4 hours to 41 F. The DS stated staff needed to start the process all over again if the food did not cool down to 60 F in 2 hours to prevent bacterial growth and for food safety.

During a review of the facility's P&P titled Hazardous Foods Cooling Monitor dated 11/15/2024, the P&P indicated, Potentially hazardous foods should be cooled from 140 F to 70 F within two hours and cooled from 70 F to 41 F or lower in an additional four hours. (IV.) Record action taken to achieve proper temperature cooling every hour on DS-23-Form A-Cooling Monitor Log, or similar form.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 55 056377 Department of Health & Human Services Printed: 09/07/2025 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 056377 B. Wing 02/27/2025

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

The Rehabilitation Center on Pico 3233 W. Pico Boulevard Los Angeles, CA 90019

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 0802 During a review of the facility's job description titled [NAME] Job Description, dated and signed by [NAME] 1

on 8/12/2022, the job description indicated, specific job functions included preparing and cooking food in a Level of Harm - Minimal harm or safe, efficient, and sanitary manner. potential for actual harm

During a review of the facility's competency checklist titled Food and Nutrition: Competency Checklist-Cook Residents Affected - Few signed and dated by [NAME] 1 and DS on 4/22/2024, the checklist indicated, [NAME] 1 needed improvements on monitoring and logging time/temperature of food and correctly utilize cool-down procedure/log.

During a review of the Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-501.14 Cooling. (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 57 C (135 F) to 21 C (70 F); P and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less. (B) TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled within 4 hours to 5 C (41 F) or less if prepared from ingredients at ambient temperature, such as reconstituted FOODS and canned tuna.

b. During a concurrent demonstration and interview on 2/25/2025 at 2:11 p.m., of checking the concentration QUAT sanitizer with Dietary Aide 4 (DA 4) and the DS, DA 4 pulled a sanitizer test strip and dipped it in the third sink for five (5) seconds. DA 4 stated he counted in his head as 1, 2, 3, 4, 5, 6, 7, 8, 9, 10. DA 4 compared the test strip in the color chart and stated it was 200 parts per million ([ppm], described the concentration of the solution and anything above 200 ppm was not acceptable because the chemical was too strong.

During a concurrent demonstration and interview on 2/25/2025 at 2:14 p.m. of checking the concentration of

the QUAT sanitizer with the DS, the DS stated QUAT sanitizer is the chemical they used for the third compartment sink to sanitize the pots and pans. The DS pulled a test strip and dipped it in the third compartment sink and counted one Mississippi, two Mississippi up to ten (10) Mississippi. The DS stated it had to be 10 seconds because that is what the manufacturer's guidelines wanted them to do. The DS stated

they needed to follow the manufacturer's guidelines to make sure the sanitizer was in the right concentration for sanitizing dishes. The DS stated if you counted 1.2.3.4.5 then it was less than 10 seconds, and the reading of the sanitizer concentration may not be accurate. The DS stated if the sanitizer reading was not accurate, it would not sanitize the dishes causing foodborne illnesses as a potential outcome for the residents. The DS stated the acceptable QUAT sanitizer concentration was only 200 ppm as anything higher than that would be harmful for the residents.

During a review of the facility's manufacturers guidelines titled, Dishwashing Procedure, undated, the guidelines indicated Test M-C 10 sanitizer solution periodically to assure solution is effective using QUAT test strips. Reading should be between 200 to 400 ppm.

During a review of the facility's test strips manufacturer's guidelines titled Quat Sanitizer Test Strips undated,

the guidelines indicated, Dip the test strip into the sanitizing solution for 10 seconds, then instantly match the resulting color with the color chart on the package to determine the concentration. The minimum reading properly diluted sanitizer solution is 200 ppm. Acceptable range 200-400 ppm.

During a review of the facility's P&P titled Washing and Sanitizing dated 11/15/2024, the P&P indicated, Chemical sanitation requires greater controls than hot water sanitation. (1) Follow manufacturer's guidelines (3) Improper test strips yield inaccurate results when testing for chemical sanitation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 55 056377 Department of Health & Human Services Printed: 09/07/2025 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 056377 B. Wing 02/27/2025

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

The Rehabilitation Center on Pico 3233 W. Pico Boulevard Los Angeles, CA 90019

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 0802 During a review of the facility's job description titled Dietary Aide dated and signed by DA 4 on 10/20/2022,

the job description indicated, specific job specification included performing dishwashing procedures Level of Harm - Minimal harm or appropriately with care for sanitizing, water temperatures and drying practices. potential for actual harm

During a review of the facility's competency checklist titled Food and Nutrition: Competency Checklist- Food Residents Affected - Few Service Worker, dated and signed by DA 4 and the DS on 4/2/2024, the checklist indicated, DA 4 was deemed competent in stating proper sanitizer solution range and correctly prepares sanitizer solution, tests concentrations.

During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration. Concentration of the sanitizing solution shall be accurately determined by using test kit or other device.

During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitation- Temperature, pH, Concentration, and Hardness.

A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times specified under 4-703.11 (C) shall meet criteria specified under 7-204.11 Sanitizers, criteria shall be used in accordance with the EPA-registered label use instructions, and shall be used as follows: (C) A quaternary ammonium compound solution shall (1) Have a minimum temperature of 24 C (75 F), (2) Have a concentration as specified under 7-204.11 and as indicated by the manufacturer's use directions included in

the labeling.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 55 056377 Department of Health & Human Services Printed: 09/07/2025 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 056377 B. Wing 02/27/2025

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

The Rehabilitation Center on Pico 3233 W. Pico Boulevard Los Angeles, CA 90019

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 0805 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Level of Harm - Minimal harm or potential for actual harm 47441

Residents Affected - Few Based on observation, interview, and record review, the facility failed to prepare foods in a form designed to meet individual needs when puree yellow zucchini did not hold its shape on the plate and the puree Spanish rice had chunks of rice for residents on puree diet (foods that are smooth with pudding like consistency).

These failures had the potential to result in difficulty in swallowing, chewing, decreased in food intake and nutrient intake to 9 of 92 residents on puree diet, resulting to unintended (not planned) weight loss and chocking (when food gets stuck in your airway, blocking the flow of air to your lungs).

Findings:

During a review of the facility's menu spreadsheet (a sheet containing the kind and amount of food each diet would receive) titled Winter Menus, dated 2/24/2025, the spreadsheet indicated residents on puree diet would include the following foods on the tray:

Puree cilantro lime chicken number 6 scoop (2/3 cup [c] a household measurement)

Gravy or sauce of choice 1 ounce (oz, a unit of measurement)

Puree Spanish rice number 8 scoop (1/2 c)

Puree zucchini and yellow squash number 10 scoop (3/8 c)

Puree bread or roll with butter or margarine number 16 scoop (1/4 c)

During an observation on 2/24/2025 at 11:54 a.m. of the puree food preparation, observed [NAME] 1 poured

the thickener in the puree foods on the steamtable without measuring it.

During an interview on 2/24/2025 at 12:01 p.m. with [NAME] 1, [NAME] 1 stated she did not use a guideline

on how puree food should look like and there was no guideline on how much amount of thickener to use. [NAME] 1 stated she just tried to make the puree foods not too watery and too thick and just enough to spread on the plate so the food could be well presented.

During an observation on 2/24/2025 at 12:25 p.m. of the trayline (an area where foods were assembled from

the steamtable to resident's plate), observed puree yellow zucchini was not holding its shape and was touching other puree food on the plate.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 55 056377 Department of Health & Human Services Printed: 09/07/2025 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 056377 B. Wing 02/27/2025

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

The Rehabilitation Center on Pico 3233 W. Pico Boulevard Los Angeles, CA 90019

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 0805 During a concurrent test tray (a process of tasting, temping, and evaluating the quality of food) on 2/24/2025 at 1:07 p.m. of puree diet with the Dietary Supervisor (DS), the DS stated the puree yellow zucchini was a Level of Harm - Minimal harm or little bit flat on the plate and it did not hold its shape as compared to other puree foods that held the scoop potential for actual harm shape. The DS stated they have spreadsheets and recipe books that contained recipes and portion sizes of

the food, and it included the amount of thickener to use. The DS stated the thickener should be measured to Residents Affected - Few achieve a smooth pudding-like consistency. The DS stated the puree food should hold its shape and not too liquify and not following the recipes could lead to a food products that were too clumpy or too watery. The DS stated the puree Spanish rice had rice particles in it and it should not be. The DS stated puree food that did not hold it shape with thin in consistency and puree Spanish rice with rice particles could potentially cause choking and difficulty in swallowing to residents. The DS further stated the residents might not eat the puree food leading to loss of appetite and weight loss.

During an interview on 2/26/2025 at 11:00 a.m., with the Registered Dietitian (RD), the RD stated they used National Dysphagia Diet ([NDD], an old and outdated national guideline for diets used for residents with difficulty swallowing and chewing) instead of the International Dysphagia Diet Standardization Initiative guidelines ([IDDSI], a global standards used for texture modified and thickened liquids for individuals with dysphagia of all ages, in all care settings, and all cultures). The RD stated the plan is to start the in-service next month. The RD stated puree diets are for residents with dysphagia (difficulty swallowing), difficulty chewing and missing teeth. The RD stated puree diet should contain food that are smooth, homogenous (similar) consistency, pudding or mashed potato consistency. The RD stated if the food went flat and spread out on the plate, it might be too thin and grains in puree rice was not okay. The RD stated the puree rice must have no particles and the potential outcome for too thin of a food and rice with particles for residents on puree diets would be risk of aspiration (inhaling something into the airways, usually food, saliva or stomach contents).

During a review of the facility's policies and procedures (P&P) titled Menus dated 11/15/2024, the P&P indicated, To ensure that the facility provides meals to residents that meet the requirements of the Food and Nutrition Board of the National Research Council of the National Academy of Sciences.

During a review of the facility's P&P titled Standardized Recipes dated 11/15/2024, the P&P indicated, To provide the dietary department with guidelines for the use of standardized recipes. Food products prepared and served by the dietary department will utilize standardized recipes. Procedure:

Standardized recipes are provided with the menu cycle.

Standardized recipes have adjustments for yields needed.

Standardized recipes will have adjustments or separate recipes for therapeutic and consistency modification.

Recipes will have diet modifications noted.

The dietary manager or designee will monitor and routinely verify the recipes used by the cooks.

During a review of the facility's diet manual titled Puree Level 1 dated 11/15/2025, the diet manual indicated, Puree all foods to the consistency of smooth, moist mashed potatoes or pudding-like consistency (use appropriate recipes). No course textures, chunks, lumps or particles are allowed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 55 056377 Department of Health & Human Services Printed: 09/07/2025 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 056377 B. Wing 02/27/2025

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

The Rehabilitation Center on Pico 3233 W. Pico Boulevard Los Angeles, CA 90019

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 0805 During a review of the facility's recipe titled Pureed Potatoes, Pasta, Rice, and Other Grains, undated, the recipe indicated, Ingredients: rice cooked drained 2 1/2 cup, broth, hot or hot 2% milk 1 1/4 cup, food Level of Harm - Minimal harm or thickener 1 1/2 teaspoon. Directions: (1) Remove portions required from regular prepared recipe and drain, if potential for actual harm necessary. Place in food processor or blender and process until smooth. Amount of thickener would vary slightly. Start with 1 1/2 teaspoon and add gradually. Ensure mix achieves smooth, lump free, and extremely Residents Affected - Few thick consistency.

During a review of the facility's recipe titled Pureed Vegetables, undated, the recipe indicated, Ingredients: seasoned vegetables; cooked and drained 2 1/2 cup, food thickener 1 1/2 teaspoon. Directions: Remove portions required from regular prepared recipe, drain and reserve cooking liquid. Place in food processor or blender and process until smooth. Amount of thickener would vary slightly. Start with 1 1/2 teaspoon and add gradually. Ensure mix achieves smooth, lump free, and extremely thick consistency.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 55 056377 Department of Health & Human Services Printed: 09/07/2025 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 056377 B. Wing 02/27/2025

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

The Rehabilitation Center on Pico 3233 W. Pico Boulevard Los Angeles, CA 90019

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 47441

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when:

1. Kitchen equipment and kitchen areas were not cleaned and sanitized.

a. Reach in refrigerator vents had dust buildup by the entrance door

b. Reach in freezer B bottom shelves had dirt debris

c. Reach in freezer shelves had dust buildup.

d. Dry storage area shelves had dust buildup.

e. Walk-in refrigerator vents had dust buildup.

2. Kitchen equipment and utensils were not maintained in its proper condition, smooth and easy to clean.

a. Torn gasket in Freezer A.

b. Two racks in the walk-in refrigerator had amber discoloration, rusted, cracked and chipped.

c. Ten residents cracked trays.

d. Scoop drawer was rusted.

3. Seven (7) dented cans were stored with non-dented cans.

4. Staff did not prevent cross-contamination (transfer of harmful bacteria from one place to another) during food preparation.

a. Staff used the same whisk (a kitchen tool made of curve wire that is used to stir or beat such as eggs and cream) for puree chicken, puree zucchini, puree bread and puree Spanish rice without washing it after each use.

b. Staff used the same brown chopping board and knife for chopping board and knife for chopping cooked chicken and vegetables without washing it.

5. Staff did not perform handwashing

a. After touching their watches during food preparation and food handling.

b. Staff did not handwash when touching soiled dishes then putting away clean dishes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 55 056377 Department of Health & Human Services Printed: 09/07/2025 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 056377 B. Wing 02/27/2025

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

The Rehabilitation Center on Pico 3233 W. Pico Boulevard Los Angeles, CA 90019

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 6. Staff failed to cool down turkey sausages and breaded chicken on 2/23/2025 and it was indicated in the cooling log. Level of Harm - Minimal harm or potential for actual harm 7. Pots and pans were stacked wet in the storage area

Residents Affected - Some 8. Quaternary ammonium compound (QUAT, a chemical that disinfect) sanitizer concentrations were not checked correctly.

These failures had the potential to result in harmful bacterial growth and cross contamination that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 90 of 92 medically compromised residents who received food and ice from the kitchen.

Findings:

1. a. During an observation on 2/24/2025 at 8:51 a.m., of the reach in refrigerator by the entrance door, observed the vent had dust buildup and the bottom shelves had food debris.

b. During an observation on 2/24/2025 at 8:54 a.m., of the reach-in freezer B, observed food debris at the bottom shelves.

c. During an observation on 2/24/2025 at 8:58 a.m., of the reach in freezer shelves, observed black dust buildup on the freezer walls.

During a concurrent observation and interview on 2/24/2025 at 9:08 a.m. with the Dietary Supervisor (DS),

the DS stated staff just cleaned the freezer and refrigerator yesterday, but they do a detail clean once a month and the last time it was detailed clean was two (2) weeks ago. The DS stated the freezer vent had dust, there were food debris on the bottom of the freezer shelves and the reach in freezer shelves had dust buildup. The DS stated it was important to have freezers and refrigerators free of dust, dirt and food debris due to cross-contamination to food in the freezer and refrigerator. The DS stated the potential outcome of cross-contamination of food would be foodborne illnesses to residents.

During an observation and interview on 2/24/2025 at 9:21 a.m. with the DS, the DS stated the refrigerator vents had dust buildup and maintenance needed to clean it as it was not okay due to cross-contamination.

d. During an observation on 2/24/2025 at 9:24 a.m. of the dry storage area rack where paper products were stored, observed rack had dust buildup.

During a concurrent observation and interview on 2/24/2025 at 9:45 a.m., of the rack in the dry storage area with the DS, the DS stated the rack had dust buildup and it was not okay because they need to worry about little critters (animal) and cross-contamination of food. The DS stated residents could have foodborne illness from food contamination.

e. During an observation on 2/24/2025 at 9:33 a.m., of the walk-in refrigerator, observed refrigerator vents had dust buildup.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 55 056377 Department of Health & Human Services Printed: 09/07/2025 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 056377 B. Wing 02/27/2025

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

The Rehabilitation Center on Pico 3233 W. Pico Boulevard Los Angeles, CA 90019

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 During a concurrent observation and interview on 2/24/2025 at 10:06 a.m., with the DS, the DS stated there was a dust buildup in the vent of the walk-in refrigerator and it was not okay due to contamination to food. Level of Harm - Minimal harm or The DS stated the maintenance staff needed to clean more frequently instead of once a month. potential for actual harm

During a review of the facility's policies and procedures (P&P) titled Sanitation of Reach in Refrigerator, Residents Affected - Some dated 11/15/2024, the P&P indicated, The reach in refrigerator will be maintained in a sanitary condition.

During a review of the facility's P&P titled Freezer Operation and Cleaning, dated 11/15/2024, the P&P indicated, The freezer will be cleaned periodically, as necessary.

During a review of the facility's P&P titled Food Receiving and Storage, dated 11/15/2024, the P&P indicated, (2) The focus of protection for dry storage is to keep non-refrigerated foods, disposable dishware, and napkins in a clean, dry area, which is free from contaminants.

During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be cleaned: (1) Except as specified in (B) of this section, before use with a different type of raw animal food such as beef, fish, lamb, pork or poultry; (2) Each time there is a change from working with raw foods to working with ready-to-eat food; (3) Between uses with raw fruits and vegetables and with time/temperature control for safety food. (4) Before using or storing a food temperature measuring device, and (5) At the time during the operation when contamination may have occurred.

During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated,4-602.13 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.

During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-602.12 Cooking and Baking Equipment. (A) The food contact surfaces of cooking and baking equipment shall be cleaned at least every 24 hours. This section does not apply to hot oil cooking and filtering equipment if it is cleaned as specified subparagraph 4-602.11 (D)(6).

2. a. During an initial kitchen tour observation on 2/24/2025 at 9:01

a.m., of the reach in freezer A, observed torn front gasket.

During a concurrent observation and interview on 2/24/2025 at 9:16 a.m. with the DS, the DS stated the reach in freezer A bottom gaskets were torn and it was not acceptable because the freezer would not be working efficiently and would not hold temperature for food safety. The DS stated it was important to maintain freezer temperatures to ensure foods are edible and temperatures are in the acceptable range. The DS stated residents could have foodborne illnesses if food becomes inedible due to unacceptable temperatures.

b. During an observation on 2/24/2025 at 9:33 a.m., of the walk-in refrigerator, observed the racks had chips, amber discoloration and rust.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 55 056377 Department of Health & Human Services Printed: 09/07/2025 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 056377 B. Wing 02/27/2025

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

The Rehabilitation Center on Pico 3233 W. Pico Boulevard Los Angeles, CA 90019

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 During a concurrent observation and interview on 2/24/2025 at 10:10 a.m., with the DS, the DS stated the was a brown discoloration on the racks due to condensation and it was not easy to clean. The DS stated the Level of Harm - Minimal harm or racks had cracks and could cause cross-contamination to food leading to food borne illnesses for the potential for actual harm residents as a potential outcome.

Residents Affected - Some During a review of the facility's P&P titled Food Storage, dated 11/15/2025, the P&P indicated, (d) Shelving should be sturdy and provided with a surface which is smooth and easily cleaned.

c. During a concurrent observation and interview on 2/25/2025 at 10:10 a.m., of the resident's tray with the DS, observed ten resident's tray had cracks, chips and loss its glaze. The DS stated crack trays were not acceptable as the crack particles could go to the food as physical contamination (refers to the presence of any hair, glass, metals, jewelry and dirt in the food) and could injure the residents.

During a review of the facility's P&P titled Discarding Chipped/Cracked Dishes and Single Service Items dated 11/15/2025, the P&P indicated, Policy: The dietary staff will maintain a sanitary environment in the dietary department by discarding compromised service ware and single service items. Chipped, cracked, or non-sanitizing surfaces on china and glassware will not be used. The dietary staff will discard chipped or cracked dish or glassware.

d. During an observation on 2/25/2025 at 10:34 a.m. of the scoop drawer, observed the scoop drawer was rusted, and scoops were stored in it.

During a concurrent observation and interview on 2/25/2025 at 10:36 a.m. of the scoop drawer with the DS,

the DS stated the scoop drawer had chips, the paint was coming off and there was brown in color discoloration that looked like rust. The DS stated the scoops should not be stored in there as it could cause food contamination.

During a review of the facility's P&P titled Food Contaminants dated 11/15/2024, the P&P indicated, Physical Contamination: are foreign objects that may inadvertently enter the food. Examples include but not limited to, staples, fingernails, jewelry, hair, glass, metal shavings from can openers, and pieces or fragments of bones from fish or chicken for example.

During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. (3) Free of sharp internal angles, corners, and crevices, (4) Finished to have smooth welds and joints.

3. During an observation on 2/24/2025 at 9:24 a.m., of the dry storage shelves, observed two (2) dented cans stored with non-dented cans.

During a concurrent observation and interview on 2/24/2025 at 9:48 a.m. with the DS, the DS stated they have a separate area to place all the dented can from non-dented cans as they could not use dented cans due to cross-contamination. The DS stated there were seven (7) dented cans stored with non-dented cans and it was not okay due as it could cause botulism (rare but serious bacterial infection) to the residents as a potential outcome.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 55 056377 Department of Health & Human Services Printed: 09/07/2025 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 056377 B. Wing 02/27/2025

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

The Rehabilitation Center on Pico 3233 W. Pico Boulevard Los Angeles, CA 90019

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 During a review of the facility's P&P titled Food Storage, dated 11/15/2024, the P&P indicated, (d) Dented or bulging cans should be placed in separate storage area and returned for credit. Level of Harm - Minimal harm or potential for actual harm During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-101.11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under 3-601. Residents Affected - Some 12, honestly presented. 3-201.11 Compliance with Food Law. A primary line of defense ensuring that food meets the requirements of S3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting, processing, they do not fail victim to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard.

4. a. During an observation on 2/24/2025 at 11:54 a.m., of [NAME] 1 preparing puree food, observed [NAME] 1 mixed the puree cilantro lime chicken with a whisk. [NAME] 1 rinsed the whisk in the three-compartment sink with water and placed it on trayline (an area where foods were assembled from the steamtable to resident's plate)).

During an observation on 2/24/2025 at 12:01 p.m., of [NAME] 1 preparing puree yellow zucchini, observed [NAME] 1 used the same whisk she used for the puree cilantro lime chicken to mix puree yellow zucchini without washing and sanitizing it.

During an observation on 2/24/2025 at 12:03 p.m., of [NAME] 1 preparing puree bread, observed [NAME] 1 rinsed the same whisk she used in mixing puree yellow zucchini in the three-compartment sink with water then used it to mix the puree bread.

During an observation on 2/24/2025 at 12:06 p.m., of [NAME] 1 preparing puree Spanish rice, observed [NAME] 1 rinse the same whisk she used for mixing puree bread in the three-compartment sink with water then used it to mix puree Spanish rice.

During an interview on 2/24/2025 at 1:38 p.m. with the DS, the DS stated he expected staff to use different utensils for each food items during preparation of food or go wash and sanitize it before reusing the utensils.

The DS stated it was important to prevent cross contamination of one food to another due to allergy ingredient contamination. The DS stated allergic reaction for residents would be the potential outcome from using the utensil or chopping board with different food and residents could also get hospitalized because of this.

During a review of the facility's P&P titled Washing and Sanitizing-Dietary, dated 11/15/2025, the P&P indicated, To provide food and nutritional service employees with guidelines for washing and sanitizing dietary related items and equipment. (3) Low temperature dishwasher (chemical sanitation) (a) Wash - 120 F; and (b) Final rinse - 50 parts per million (ppm) hypochlorite (chlorine) on dish surface in final rinse. Manual washing and sanitizing: 3-step process is used to manually wash, rinse and sanitize dishware correctly.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 55 056377 Department of Health & Human Services Printed: 09/07/2025 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 056377 B. Wing 02/27/2025

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

The Rehabilitation Center on Pico 3233 W. Pico Boulevard Los Angeles, CA 90019

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 b. During an observation on 2/24/2025 at 12:59 p.m. of the food preparation, observed [NAME] 2 used the same brown chopping board and knife in chopping cooked chicken and green beans for finely chopped diets. Level of Harm - Minimal harm or potential for actual harm During an interview on 2/25/2025 at 9:41 a.m. with the DS, the DS stated staff used different colors of chopping board to prevent cross-contamination. The DS stated they used white chopping board for cooked Residents Affected - Some vegetables only and brown for cooked meats. The DS stated staff should be using a brown for cooked meats and white for cooked vegetables to prevent allergies contaminants and foodborne illnesses.

During a review of the facility's P&P titled Safe Food Preparation, dated 11/15/2024, the P&P indicated, The facility follows proper sanitation and food handling practices to prevent the outbreak of foodborne illness. Safe Food Preparation: (3) Examples of ways to reduce cross-contamination include but not limited to: (d) Clean and sanitize work surfaces, including cutting boards and food-contact equipment (e.g., food processors, blenders, preparation tables, can openers, and slicers), between uses and consistent with applicable code.

During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-307.11 Miscellaneous Sources of Contamination. Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301-3-306.

5. a. During an observation on 2/24/2025 at 9:42 a.m., of the food preparation, [NAME] 1 was wearing a wristwatch while cooking food.

During an observation on 2/24/2025 at 12:31 p.m. during trayline, observed [NAME] 1 wearing a wristwatch.

During an observation on 2/24/2025 at 12:47 p.m. of the staff dishing out (transferring) food from the steamtable to the resident's plate, observed [NAME] 1 touched her wristwatch then continued dishing out food from the steamtable to the resident's plates.

During an observation on 2/24/2025 at 12:49 p.m. of the Dietary Aide 1 (DA 1) in the trayline, DA 1 touched her watch then continued working in trayline.

During an interview on 2/242/2025 at 1:42 p.m. with the DS, the DS stated they were not allowed to wear jewelry in the kitchen and watches due to cross-contamination. The DS stated staff should watch their hands

after they touched their watches and before they go back to work to prevent food contamination.

A review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated 2-303.11 Prohibition. Except for a plain ring such as wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands.

b. During an observation on 2/25/2025 at 1:47 p.m. of the dishwashing process, observed Dietary Aide 3 (DA 3) touched the soiled dishes then went back to the cleaned area and touched the clean dishes without washing their hands.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 55 056377 Department of Health & Human Services Printed: 09/07/2025 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 056377 B. Wing 02/27/2025

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

The Rehabilitation Center on Pico 3233 W. Pico Boulevard Los Angeles, CA 90019

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 During an interview on 2/25/2025 at 1:50 p.m. with the DS, the DS stated DA 3 should be changing her gloves when going from dirty to clean area as it would contaminate the clean dishes with DA 3's Level of Harm - Minimal harm or contaminated hands. The DS stated this could cause foodborne illness from contaminated dishes as a potential for actual harm potential outcome.

Residents Affected - Some During a review of the facility's P&P titled Hand Hygiene dated 11/15/2024, the P&P indicated, Facility staff, visitors, and volunteers must perform hand hygiene procedures in the following circumstances: (A) Wash hand with soap and water:

Before and after food preparation

During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and: (A)

After touching bare human body parts other than clean hands and clean, exposed portions of arms; P (B)

After using the toilet room; P (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in 2-403.11(B); P (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using TOBACCO PRODUCTS, eating, or drinking; P (E) After handling soiled EQUIPMENT or UTENSILS; P (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; P (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; P (H) Before donning gloves to initiate a task that involves working with FOOD; P and (I) After engaging in other activities that contaminate the hands.

6. During an observation on 2/24/2025 at 9:33 a.m. in the walk-in refrigerator, observed cooked turkey sausage in a container with prepared date 2/23/2025 and with the use by date (last date that a food product can be consumed at its peak quality and safety) of 2/26/2025 and breaded chicken with prepared date 2/23/2025 and with the use by date of 2/26/2025.

During a concurrent interview and record review on 2/25/2025 at 10:18 a.m. with the DS, Cooling Monitoring Form dated 2/2025 was reviewed. The Cooling Monitoring Form indicated, there were no breaded chicken and sausage times and temperatures monitoring entry on 2/23/2025. The DS sated, there was no entry for sausage and breaded chicken on 2/23/2025 and staff were to monitor time and temperature for the sausage and breaded chicken. The DS stated it was important to cool down food safely to prevent bacterial growth in food. The DS stated without proper cool down of food, residents could get food poisoning and foodborne illnesses as a potential outcome.

During a review of the facility's P&P titled Hazardous Foods Cooling Monitor dated 11/15/2024, the P&P indicated, Potentially hazardous foods should be cooled from 140 degrees Fahrenheit ([ F], a scale of temperature) to 70 F within two hours and cooled from 70 F to 41 F or lower in an additional four hours. (IV.)

Record action taken to achieve proper temperature cooling every hour on DS-23-Form A-Cooling Monitor Log, or similar form.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 55 056377 Department of Health & Human Services Printed: 09/07/2025 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 056377 B. Wing 02/27/2025

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

The Rehabilitation Center on Pico 3233 W. Pico Boulevard Los Angeles, CA 90019

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 During a review of the Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-501.14 Cooling. (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 57 C (135 F) to Level of Harm - Minimal harm or 21 C (70 F); P and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less. (B) potential for actual harm TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled within 4 hours to 5 C (41 F) or less if prepared from ingredients at ambient temperature, such as reconstituted FOODS and canned tuna. Residents Affected - Some 7. During an observation on 2/25/2025 at 2:01 p.m. of the pots and pans washing process, observed employees stacking pots and pans wet.

During a concurrent observation and interview on 2/25/2025 at 2:14 p.m. of the pots and pans storage area with the DS, the DS stated the pans were stacked wet and were not completely dry as there were still water droplets. The DS stated they could not stack pans wet because bacteria could grow on the stacked wet pans causing cross-contamination and chemical contamination as a potential outcome. The DS stated, staff needed to air dry pots and pans.

During a review of the facility's P&P titled Pot and Pan Cleaning, dated 11/15/2024, the P&P indicated, (IX) Invert the pots and pans and place them on a drying rack or counter. Place small items in a flat bottom dish rack to dry. (X.) Allow items to air dry. Do not use a towel. (XI) When items are dry, store them in the proper storage area.

During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-901.11 Equipment and Utensils, air-drying required. After cleaning and sanitizing equipment and utensils: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface sanitizing solutions), before contact with food and; (B) May not be cloth dried except that utensils that have been air-dried may be polished with cloths that are maintained clean and dry.

8. During a concurrent demonstration and interview on 2/25/2025 at 2:11 p.m., of checking the concentration QUAT sanitizer with Dietary Aide 4 (DA 4) and the DS, DA 4 pulled a sanitizer test strip and dipped it in the third sink for five seconds. (surveyor counting 1001, 1002, 1003, 1004, 1005). DA 4 stated he counted in his head as 1, 2, 3, 4, 5, 6, 7, 8, 9, 10.

During a concurrent demonstration and interview on 2/25/2025 at 2:14 p.m. of checking the concentration of

the QUAT sanitizer with the DS, the DS stated QUAT sanitizer is the chemical they used for the third compartment sink to sanitize the pots and pans. The DS pulled a test strip and dipped it in the third compartment sink and counted one Mississippi, two Mississippi up to ten (10) Mississippi. The DS stated it had to be 10 seconds because that is what the manufacturer's guidelines wanted them to do. The DS stated

they needed to follow the manufacturer's guidelines to make sure the sanitizer was in the right concentration for sanitizing dishes. The DS stated if you counted 1.2.3.4.5 then it was less than 10 seconds, and the reading of the sanitizer concentration may not be accurate. The DS stated if the sanitizer reading was not accurate, it would not sanitize the dishes causing food borne illnesses as a potential outcome for the residents.

During a review of the facility's test strips manufacturer's guidelines titled Quat Sanitizer Test Strips undated,

the guidelines indicated, Dip the test strip into the sanitizing solution for 10 seconds, then instantly match the resulting color with the color chart on the package to determine the concentration.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 55 056377 Department of Health & Human Services Printed: 09/07/2025 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 056377 B. Wing 02/27/2025

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

The Rehabilitation Center on Pico 3233 W. Pico Boulevard Los Angeles, CA 90019

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 During a review of the facility's P&P titled Washing and Sanitizing dated 11/15/2024, the P&P indicated, Chemical sanitation requires greater controls than hot water sanitation. (1) Follow manufacturer's guidelines Level of Harm - Minimal harm or (3) Improper test strips yield inaccurate results when testing for chemical sanitation. potential for actual harm

During an interview on 2/26/2025 at 11:00 a.m., with the Registered Dietitian (RD), the RD stated she does Residents Affected - Some monthly sanitation in the kitchen and the last time she did it was 1/2024 to ensure staff follow protocol for food safety and infection control. The RD stated rust and dirt are contaminants to food and residents could get sick from food poisoning due to contaminated foods.

During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration. Concentration of the sanitizing solution shall be accurately determined by using test kit or other device.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 55 056377 Department of Health & Human Services Printed: 09/07/2025 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 056377 B. Wing 02/27/2025

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

The Rehabilitation Center on Pico 3233 W. Pico Boulevard Los Angeles, CA 90019

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 0814 Dispose of garbage and refuse properly.

Level of Harm - Minimal harm or 47441 potential for actual harm Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly Residents Affected - Few when three of three dumpsters (large trash container designed to be emptied into a truck) were not completely closed or covered when not actively used. This failure had a potential to result to attracting birds, flies, insects, pest and possibly spread infection to 90 of 92 facility residents.

Findings:

During an observation on 2/25/2025 at 9:39 a.m. of the dumpster, two (2) of 3 dumpsters were overflowing with trash and not completely covered when not actively used.

During an observation on 2/25/2025 at 2:08 p.m. of the dumpster, 3 of 3 dumpsters were overflowing with trash and not completely covered when not actively used.

During an observation on 2/25/2025 at 2:23 p.m. of the dumpster, 3 of 3 dumpsters were overflowing with trash and not completely covered when not actively used. Observed the first dumpster had an uncovered gap in the middle, second dumpster was overflowing with trash and the third dumpster was not completely closed.

During a concurrent observation and interview on 2/25/2025 at 2:30 p.m. with the Dietary Supervisor (DS),

the DS stated the first dumpster cover was broken causing the middle gap, the second dumpster was overflowing with trash, and it was not okay. The DS stated the third dumpster was not completely closed and

it was not okay because it was not actively in use. The DS stated the dumpster needed to be covered to prevent animals going in the trash and getting the trash out that could cause bacterial, and disease spread and infection. The DS stated the boxes of soda were not broken down in the second dumpster causing it to overflow.

During an interview on 2/25/2025 at 10:34 a.m. with the Maintenance Director (MND), the MND stated the lids of the dumpsters must be closed after throwing the trash. The MND stated staff could not overfill the trash for infection control as it could attract pest and other animals.

During a review of the facility's policies and procedures (P&P) titled Dispose of Garbage and Refuse dated 11/15/2024, indicated The facility properly disposes of garbage and refuse. (1) Garbage and refuse containers are maintained in good condition (no leaks) and waste is properly contained in dumpsters or compactors with lid covered. (3) Garbage storage shall be maintained in a sanitary condition to prevent the harborage and feeding of pests.

During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 5-501.113 Covering Receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered: (A) Inside food establishment if the receptacles and units: (1) Contain food residue and are not in continuous use; or (2) After they are filled; and 174 (B) With tight-fitting lids or doors if kept outside the food establishment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 55 056377 Department of Health & Human Services Printed: 09/07/2025 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 056377 B. Wing 02/27/2025

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

The Rehabilitation Center on Pico 3233 W. Pico Boulevard Los Angeles, CA 90019

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 0814 During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 5-501.116 Cleaning Receptacles. Proper storage and disposal of garbage and refused are necessary to minimize the Level of Harm - Minimal harm or development of odors, prevent such waste from becoming an attractant and harborage of breeding place for potential for actual harm insects and rodents, and prevent the soiling of food preparation and food service areas. Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be possible source of Residents Affected - Few contamination of food, equipment, and utensils. Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. Proper equipment and supplies must be made available to accomplish thorough and proper cleaning of garbage storage areas and receptacles so that unsanitary conditions can be eliminated.

During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, A review of Food Code 2017, indicated, 5-501.15 Outside receptacles. (A) Receptacles and waste handling units for REFUSE, recyclables, and returnable used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 55 056377 Department of Health & Human Services Printed: 09/07/2025 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 056377 B. Wing 02/27/2025

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

The Rehabilitation Center on Pico 3233 W. Pico Boulevard Los Angeles, CA 90019

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 43851 potential for actual harm Based on interview and record review, the facility failed to ensure two of nine sampled facility employees Residents Affected - Few (Licensed Vocational Nurse [LVN] 6 and Restorative Nurse Assistant [RNA] 1) were screened with documented evidence for PPD test (a purified protein derivative [PPD] skin test is a test that determines if you have tuberculosis [TB], a serious infection, usually of the lungs) and clearance as required by the facility's policy and procedure.

This deficient practice had the potential to place residents, visitors, and facility staff to tuberculosis exposure by allowing staff to work without proof they were either negative for or did not have symptoms of tuberculosis infection.

Findings:

During a review of LVN 6's employee file, dated 1/12/2025, LVN 6's employee file indicated LVN 6 solely answered the facility's questionnaire for the Healthcare Worker Tuberculosis Symptom Screen. LVN 6's employee file indicated the PPD skin test documentation and chest x-ray documentation were both blank.

The employee file did not indicate whether LVN 6 previously had tested positive for tuberculosis.

During a review of RNA 1's employee file, dated 9/20/2024, RNA 1's employee file indicated RNA 1 answered the facility's Team Member Health Questionnaire and the facility's Healthcare Worker Tuberculosis Symptom Screen. RNA 1's employee file indicated the PPD skin test documentation and chest x-ray documentation were both blank. The employee file did not indicate whether RNA 1 previously had tested positive for tuberculosis.

During an interview on 10/18/2025 at 10:18 AM with Registered Nurse Consultant 1 (RNC-an expert advisor, helping other healthcare facilities and teams improve their nursing practices, patient care quality, and overall systems by offering advice, evaluating current procedures, and teaching new methods), RNC 1 stated she could not explain why the facility allowed an employee who did not have a TB screen and clearance to work. RNC 1 stated an employee without a TB screen and clearance could expose residents to TB if the facility did not screen and clear the employee.

During an interview on 2/27/2025 at 12:44 PM with the ADM and the Director of Nursing (DON), the ADM and DON stated if the facility did not have proof of a staff member's PPD test and clearance, the employee would need to have proof of the test and clearance before the facility would allow the employee to work. The ADM and DON stated they would follow their policy for TB testing.

During a review of the facility's policy and procedure (P&P) titled, Tuberculosis - Screening of Resident and Healthcare Workers, dated 9/1/2021, the P&P indicated the facility would screen their healthcare worker (HCW) annually. The P&P indicated the facility would perform a single step tuberculosis skin test or IGRA (Interferon Gamma Release Assay, a blood test that detects tuberculosis) unless the HCW was previously positive for tuberculosis. The P&P indicated the HCW was previously positive for tuberculosis, the facility would have the HCW complete the tuberculosis screening questionnaire followed by a chest x-ray if the HCW had symptoms of tuberculosis.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 55 056377 Department of Health & Human Services Printed: 09/07/2025 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 056377 B. Wing 02/27/2025

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

The Rehabilitation Center on Pico 3233 W. Pico Boulevard Los Angeles, CA 90019

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 0912 Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50296

Residents Affected - Some Based on observation, interview and record review the facility failed to ensure 17 of 38 resident rooms (rooms 101, 102, 103, 104, 111, 112, 113, 214, 215, 216, 217, 218, 219, 220, 221, 222, and 238) met the requirement of that each resident must have at least 80 square feet of useable living space in multiple resident rooms and at least 100 square feet of useable living space for single rooms. This failure had the potential to affect the delivery of care, safety and wellbeing of the residents.

Findings:

During a concurrent observation and interview on 2/27/25 at 12:54 PM, in Resident 403's room, the room was clean and free from clutter and obstruction. Resident 403 stated the room is clean and she can move freely in the room without any issue. Resident 403 stated the room is not cluttered.

During an interview on 2/27/25 at 1:00 PM with Certified Nurse Assistant (CNA) 2, CNA 2 stated he can move freely in his assigned rooms and perform his duties without obstruction.

During a review of the Client Accommodations Analysis dated 2/27/25, the Client Accommodations Analysis indicated the room measurements for the following rooms:

Room # Room Size Number of Beds

101 236.12 square feet 3

102 243.45 square feet 3

103 237.45 square feet 3

104 231.92 square feet 3

111 230.84 square feet 3

112 228.46 square feet 3

113 228.35 square feet 3

214 229.59 square feet 3

215 228.53 square feet 3

216 229.16 square feet 3

217 229.01 square feet 3

218 543.98 square feet 6

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 55 056377 Department of Health & Human Services Printed: 09/07/2025 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 056377 B. Wing 02/27/2025

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

The Rehabilitation Center on Pico 3233 W. Pico Boulevard Los Angeles, CA 90019

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 0912 219 228.89 square feet 3

Level of Harm - Potential for 220 228.99 square feet 3 minimal harm 221 229.81 square feet 3 Residents Affected - Some 222 227. 76 square feet 3

238 393.41 square feet 3

During a review of the facility's Room Variance Waiver dated 4/28/24 indicated rooms 101, 102, 103, 104, 110, 111, 112, 113, 214, 215, 216, 217, 219, 220, 221, and 238 were less than 80 square feet and were approved for the room waiver. The Room Variance Waiver also indicated room [ROOM NUMBER] had more than four beds and was approved for the room waiver.

During multiple observations in the affected rooms during the recertification from 2/24/25 to 2/27/25, the deliveries of care to the residents were affected by the room sizes and there were adequate spaces for residents and staff moving freely.

During a review of the facility's policy and procedure (P&P) titled, Bedroom Measurements, dated 3/23, the P&P indicated the facility provides rooms which measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 55 056377 Department of Health & Human Services Printed: 09/07/2025 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 056377 B. Wing 02/27/2025

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

The Rehabilitation Center on Pico 3233 W. Pico Boulevard Los Angeles, CA 90019

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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49836 potential for actual harm Based on observation, interview, and record review, the facility failed to provide a functioning call light for Residents Affected - Few one sampled resident (Resident 86). This deficient practice had the potential to result in a delay in meeting Resident 86's needs for hydration, toileting, and activities of daily living.

Findings:

A review of the Admission Record for Resident 86 indicated the resident was admitted to the facility on [DATE REDACTED], with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), schizophrenia (a mental illness that is characterized by disturbances in thought), muscle weakness, and gait and mobility abnormalities (change in walking pattern).

A review of the quarterly Minimum Data Set (MDS - a resident assessment tool) dated 1/22/2025, indicated Resident 86 had moderate cognitive impairment a decline in thinking and memory that makes it hard to complete complex tasks) and needed assistance for toilet use, personal hygiene, and bathing.

During a concurrent observation and interview on 2/24/2025 at 10:48 AM, Resident 86 was observed using

the call light. The light above the door was not flashing and there was no audible sound to indicate the call light was activated. The certified nursing assistant (CNA 6), who was outside in the hallway checked Resident 86's call light and stated the call light was not working. CNA 6 stated I will have maintenance fix the call light right away.

A review of Resident 86's functional and bed mobility care plan last reviewed on 1/29/2025, indicated multiple interventions including having the call light within reach and to encourage the resident to call for assistance.

During an interview on 2/26/2026 at 11:21 AM, the maintenance director (MND) stated the call lights were supposed to be checked monthly and as needed to ensure they were working. The MND stated he was not aware that Resident 86's call light was not functioning until he was informed by CNA 6. MND further stated that he was unsure when the last time Resident 86's call light was checked because they did not keep a log for the checks.

A review of the facility's policy and procedure titled, Resident Call System, and last revised March 2023, indicated the facility should be adequately equipped to allow residents to call for staff assistance through a communication system. It further indicated the Environmental Services Department completed routine audits and maintenance to ensure all portions of the system are functioning.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 55 056377

F-F760

Findings:

During a review of Resident 50's Admission Record indicated the resident was admitted to the facility on [DATE REDACTED] with diagnoses including hemiplegia (a severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (a mild or partial weakness or loss of strength on one side of the body) following cerebral infarction (a stroke that occurs when blood flow to the brain is blocked) affecting left non-dominant side, hypertension (high blood pressure), cardiomegaly (a condition where the heart is larger than normal), atrial fibrillation (AF, abnormal heartbeat), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).

During a review of the Minimum Data Set (MDS - a resident assessment tool) dated 9/26/24 the MDS indicated Resident 50's cognitive skills (mental activities including thinking, reasoning, understanding, learning, and remembering) for daily decision-making was moderately impaired. Resident 50's MDS indicated the resident required setup for eating and oral hygiene, required substantial assistance for personal hygiene and was dependent on staff physical assistance for bathing or showering, dressing, getting in and out of bed or a wheelchair, and toileting.

During a review of the History and Physical (H&P) dated 2/29/2024 the H&P indicated Resident 50 had the capacity to understand and make decisions.

A review of Resident 50's Order Summary Report indicated:

-Apixaban (Eliquis, an anticoagulant, a blood thinner) 5 (five) milligrams (mg - unit of measure of weight) give one tablet by mouth every 12 hours, scheduled at 9 a.m., and 9 p.m., for AF, order date 4/26/2023.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 55 056377 Department of Health & Human Services Printed: 09/07/2025 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 056377 B. Wing 02/27/2025

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

The Rehabilitation Center on Pico 3233 W. Pico Boulevard Los Angeles, CA 90019

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 0759 -Amlodipine (Norvasc, a medication used to treat high blood pressure) 5 mg, give one tablet by mouth one time a day, scheduled at 9 a.m., for hypertension, hold if systolic blood pressure (SBP, when the heart beats, Level of Harm - Minimal harm or top number) is less than 110 millimeters of mercury [mm Hg]), (mmHg - unit of measure), order date potential for actual harm 8/28/2024.

Residents Affected - Few -Lexapro (used to treat depression, a constant feeling of sadness and loss of interest) 5 mg, give one tablet by mouth one time a day, scheduled at 9 a.m., for depressive disorder manifested by (m/b) verbalization of sadness, order date 10/18/2024.

-Aspirin Enteric Coated (EC) 81 mg, give one tablet by mouth one time a day, scheduled at 9 a.m., for myocardial infarction (MI, also known as a heart attack, occurs when blood flow to the heart is blocked) prophylactically (PPX, measures designed to preserve health), order date 6/17/2020.

-Docusate Sodium 100 mg, give one capsule by mouth two times a day, scheduled at 9 a.m., and 5 p.m., for constipation, hold for loose bowel movement, order date 10/18/2024.

-Calcium 500 mg with Vitamin D 200 units (unit of measure), give one tablet by mouth one time a day, scheduled at 9 a.m., for supplement, order date 10/18/2024

-Acetaminophen (Tylenol, used to treat pain) 325 mg, give two tablets (650 mg) by mouth every six hours as needed for pain management. Not to exceed three grams (gm - a unit measure of weight) from all sources in 24 hours, order date 8/28/2024

During a review of Resident 50's, Care Plans, the care plans for Resident 50 indicated the following:

a. Hypertension (HTN) related to lifestyle and stroke, dated 3/27/2020. The interventions included instructions to give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension (a sudden drop in blood pressure when standing) and increased heart rate (tachycardia) and effectiveness.

b. Black Box Warning (a serious warning given by the Food and Drug Administration [FDA] for drugs or drug classes that may cause serious harm or death) for use of Apixaban (Eliquis), dated 3/27/2020. Resident 50's care plan goal indicated; the resident will not experience side effects/ interactions with the use of Apixaban (Eliquis).

c. Risk for repeat Cardiovascular Accident (CVA) as resident had a CVA prior to admission, revision date 2/6/2025, and goal indicated to minimize risk with interventions. Interventions indicated, administer medication(s) as ordered.

d. Risk for adverse reaction related to polypharmacy, revision date 2/6/2025. Resident 50's care plan interventions included review resident's medications with MD/Consultant pharmacist for .proper dosing, timing and frequency of administrations .

e. Anticoagulant therapy, Apixaban for atrial fibrillation, at risk for active bleeding ., revision date 2/6/2025. Resident 50's care plan intervention indicated give Apixaban 5 mg by mouth every 12 hours for AF . Resident/family/caregiver teaching to include the following: take/give medication at the same time each day.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 55 056377 Department of Health & Human Services Printed: 09/07/2025 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 056377 B. Wing 02/27/2025

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

The Rehabilitation Center on Pico 3233 W. Pico Boulevard Los Angeles, CA 90019

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 0759 f. On Lexapro related to depression manifested by verbalization of sadness. Resident 50's care plan goal indicated, the resident will experience no adverse side effects from medication use .and resident's care plan Level of Harm - Minimal harm or intervention indicated, administer medications as ordered potential for actual harm

During a concurrent observation and interview on 2/25/2025 at 10:17 a.m., with a Licensed Vocational Nurse Residents Affected - Few (LVN) 3 on Station 2 at Medication Cart (MedCart) 2, LVN 3 stated she was preparing the morning medications for Resident 50 that was scheduled for 9 a.m.

During a medication pass observation on 2/25/2025 at 10:20 a.m., with LVN 3, LVN 3 prepared the following morning medications, scheduled for 9 a.m., administration for Resident 50.

-Apixaban 5 mg, one tablet

-Amlodipine 5 mg, one tablet

-Lexapro 5 mg, one tablet

-Aspirin Enteric Coated (EC) 81 mg, one tablet

-Docusate Sodium 100 mg, one capsule

-Calcium 500 mg with Vitamin D 200 units, one tablet

-Acetaminophen 325 mg, two tablets (650 mg).

During a concurrent observation and interview on 2/25/2025 at 10:27 a.m., with LVN 3, LVN 3 stated she prepared for Resident 50 a total of seven medications, one of the seven medications was Tylenol an as needed (PRN) medication for pain. LVN 3 entered Resident 50's room to administer the medications. Resident 50 stated she did not want the stool softener, docusate sodium or the calcium, and stated she will take the rest of the medications.

During an interview on 2/25/2025 at 10:38 a.m., LVN 3 stated there were 17 more residents to administer morning medications to, that were scheduled for 9 a.m. administration time. LVN 3 stated the supervisor and Director of Nursing (DON) was made aware of the heavy load that included four out of her 32 residents received medications through a gastrostomy tube (GT - a tube inserted through the belly that brings nutrition, fluids, and medications directly to the stomach) which takes a little more time and that she was not able to pass medications to all of residents on time.

During an earlier interview on 2/25/2025 at 10:11 a.m., with LVN 1, on Station 2, at MedCart 3, LVN 1 stated

he still had 12 more residents to pass medications scheduled for 9 a.m., out of a total of 27 residents, and he usually finished passing morning medications each day around 11:30 a.m. LVN 1 stated he notified a Registered Nurse Supervisor. LVN 1 stated it can be overwhelming especially when you tried to give the best care, not rush residents, and not make mistakes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 55 056377 Department of Health & Human Services Printed: 09/07/2025 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 056377 B. Wing 02/27/2025

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

The Rehabilitation Center on Pico 3233 W. Pico Boulevard Los Angeles, CA 90019

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 0759 During an interview on 2/25/2025 at 1:32 p.m., the DON stated licensed nurses should administer medications within an hour of the scheduled administration time, between an hour before scheduled up to an Level of Harm - Minimal harm or hour after the scheduled administration time. The DON stated the resident's physician must be notified if potential for actual harm resident's medications would be administered outside of the time frame and then following the physician's instructions if it was okay to administer the medication. Residents Affected - Few

During an interview on 2/25/2025 at 3:06 PM, the DON stated the physician was not called prior to administering medications late to Resident 50 on Station 2, MedCart 2. The DON stated the physician should have been called before administering medications late to residents.

A review of the facility's Policy and Procedure (P&P) titled, Medication Administration - General Guidelines, dated 10/2012, indicated the facility had sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. Medications were administered in accordance with written orders of the prescriber. The P&P indicated medications were administered within (60 minutes) of scheduled time, except before or after meal orders, which are administered (based on mealtimes).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 55 056377 Department of Health & Human Services Printed: 09/07/2025 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 056377 B. Wing 02/27/2025

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

The Rehabilitation Center on Pico 3233 W. Pico Boulevard Los Angeles, CA 90019

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 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Immediate **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 31333 jeopardy to resident health or safety Based on observation, interview and record review, the facility failed to ensure 11 of 20 sampled residents (Resident 1, 8, 10, 11, 32, 37, 50, 54, 66, 95, and 99), were free of significant medication error. The facility Residents Affected - Many failed to:

-Ensure Resident 50 was administered Eliquis (apixaban, an anticoagulant, a blood thinner), Norvasc (amlodipine, a medication used to treat high blood pressure), and aspirin for myocardial infarction (MI, also known as a heart attack, occurs when blood flow to the heart is blocked) prophylactically (PPX, measures designed to preserve health), in accordance with the physician's orders for eleven days during February 2025.

-Ensure Residents 10, 54, 95 and 99 were administered Eliquis in accordance with physician's orders and facility's policy and procedures titled, Medication Administration - General Guidelines to minimize the risk of adverse consequences (an undesired effect of a drug) including an increased risk of bleeding.

-Ensure Resident 1 was administered Depakote (valproic acid, a medication used to control seizures [a sudden, uncontrolled burst of electrical activity in the brain that can cause temporary changes in behavior, movement, sensation, or awareness]) on 2/20, 2/22, 2/23, and 2/25/2025 at 9 a.m., and 1 p.m., as ordered and not within 39 minutes to less than two hours of the next scheduled dose.

-Ensure Resident 37 was administered Keppra (levetiracetam a medication used to control seizures) on 2/20, 2/22, 2/23, 2/24, and 2/25/2025 at 9 a.m., and 5 p.m. daily as ordered.

-Ensure Residents 8, 11, 32 and 66 were administered medications in accordance with physician orders and facility's policy and procedures titled, Medication Administration - General Guidelines to minimize the risk of adverse consequences which could lead to a deterioration in the resident's condition, hospitalization , harm, or death.

These deficient practices resulted in:

-Residents 10, 50, 54, 95 and 99 were at increased risk of bleeding, including serious bleeding that can be fatal and increased risk of uncontrolled blood pressure, that could lead to stroke, heart attack, hospitalization , or death

-Residents 1 and 37 was placed at high risk for hepatotoxicity (liver toxicity, a condition that occurs when the liver is damaged by harmful substances, such as medications, toxins, or chemicals, which can lead to impaired liver function and, in severe cases, liver failure).

-Residents 8, 11, 32, and 66 were placed at risk for uncontrolled blood glucose (a type of sugar) levels.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 55 056377 Department of Health & Human Services Printed: 09/07/2025 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 056377 B. Wing 02/27/2025

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

The Rehabilitation Center on Pico 3233 W. Pico Boulevard Los Angeles, CA 90019

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 0760 On 2/26/2025 at 4:42 PM, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, Level of Harm - Immediate or death to a resident) was identified in the presence of the Administrator (ADM) and Director of Nursing jeopardy to resident health or (DON), regarding the facility's failure to identify and ensure Resident 1, 8, 10, 11, 32, 37, 50, 54, 66, 95, and safety 99, who were at increased risk of bleeding, toxicity or hyperglycemia (increased blood sugar) were free of significant medication error and received necessary care and services in accordance with professional Residents Affected - Many standards of practice.

On 2/27/2025 at 4:18 PM, while onsite at the facility, the IJ was removed in the presence of the ADM and DON, after the ADM submitted an acceptable Removal Plan (interventions and implementation to correct the deficient practices) which was verified and confirmed through observation, interview, and record review. The acceptable removal plan was as follows:

The Licensed Nurse completed change in condition assessments on 2/26/25 and reported the medication errors for each resident effected with the related medications. The residents would be monitored every shift for adverse reactions. Effected residents were monitored by the DON. Licensed Nurses would be re-educated by the DON before their next Med Pass or on or before 3/15/25 on the standard of practice and facility policy and procedure for administering medications and in accordance with the physician's ordered time to reduce the risk of medication error, serious injury, harm and or death.

The DON evaluated the resident medication administration assignments, including evaluation of residents on antiseizure, anticoagulants, hypertensive and anticonvulsant medications, including gastrostomy tubes, dialysis, blood pressure parameter checks, diabetics with insulin administration, controlled pain medications and seizure protocol on 2/26/25.

The DON contacted the pharmacy consultant and requested an additional medication cart on 2/26/25, which was verified. The cart would be delivered on 2/26/25. The DON redistributed the resident assignment to ensure the load over four medication carts on 2/26/25.

The Interdisciplinary Team met on 2/26/25 and developed and implemented a plan of care to closely monitor effected residents for adverse effects related to receiving medications at the wrong time resulting in a medication error on 2/25/25.

The Medical Records staff generated an audit of all in house residents medication administration records including the time of administration for all shifts, identifying any residents who were effected by the medication error. A copy of the audit was provided to the DON for review on 2/27/25.

All licensed nurses in the oncoming shifts were prioritized with re-education with the objective to achieve 100% of the licensed nurses before the start of their shift beginning 2/27/25.

The Director of Staff Development / designee would complete a medication pass observation skill competency with LVN 1 and 2 prior to the start of their shift.

Cross Reference