View Heights Conv Hosp

F-F758.

Findings:

During a review of Resident 3's Admission Record, the Admission Record indicated Resident 3 was admitted to the facility on [DATE REDACTED]. Resident 3's admitting diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). Resident 3 did not have diagnoses of depression (a common mental health condition characterized by a persistent low mood, loss of interest or pleasure in activities, and other symptoms that can significantly interfere with daily life) or anxiety (a common emotional state characterized by feelings of unease, worry, fear, and apprehension).

During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 12/15/2024,

the MDS indicated Resident 3 did not have cognitive impairments (problems with thinking, learning, or memory). The MDS indicated Resident 3 did not exhibit physical or verbal behaviors (e.g., physical aggression towards others and/or verbal aggression/threats towards others). The MDS indicated Resident 3 did not reject care. The MDS indicated Resident 3 could eat independently and was independent with mobility while in and out of bed.

During a review of Resident 3's physician orders, dated 3/21/2024, the order indicated Resident 3 was to receive Cymbalta 30 milligrams (mg, a unit of dose measurement), every morning, for depression manifested by self-isolative behavior.

During an interview, on 2/13/2025 at 11:23 a.m., with the Director of Nursing (DON), DON stated Resident 3 did not have a care plan to address or treat the self-isolative behavior the Cymbalta was ordered for on 3/21/2024. The DON stated there were non-pharmacologic interventions staff could attempt to address self-isolative behavior, prior to initiating psychotropic medications. The DON stated non-pharmacological interventions included counseling, group activities, and outdoor fitness programs. The DON stated non-pharmacological interventions should always be attempted before psychotropic medications, and stated

these interventions would be documented in a care plan. The DON stated Resident 3 should have a care plan for self-isolative behavior to monitor if non-pharmacological interventions were effective in addressing

the behavior to allow for a decrease or discontinuation of the Cymbalta.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 48 056417 Department of Health & Human Services Printed: 09/08/2025 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 056417 B. Wing 02/14/2025

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

View Heights Conv Hosp 12619 S. Avalon Blvd Los Angeles, CA 90061

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 0656 During a review of the facility's policy and procedure (P&P) titled Care Plan Guidelines, dated 12/2024, the P&P indicated the purpose of a care plan was to identify needs and develop a comprehensive, standardized Level of Harm - Minimal harm or plan of care for each resident that includes individualized & measurable objectives and timetables to meet potential for actual harm the resident's psychiatric, psychosocial, and medical needs.

Residents Affected - Few During a review of the facility's P&P titled Psychotropic Medication Use, dated 12/2024, the P&P indicated facility staff were to take a holistic approach to behavior management that involved a thorough assessment of the underlying causes of behaviors and individualized person-centered non-drug and pharmaceutical interventions. The P&P indicated psychotropic medications would be used to address behaviors only if the nondrug approaches and interventions were attempted prior to their use.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 48 056417 Department of Health & Human Services Printed: 09/08/2025 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 056417 B. Wing 02/14/2025

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

View Heights Conv Hosp 12619 S. Avalon Blvd Los Angeles, CA 90061

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

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

F 0658 Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47286 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse Residents Affected - Few (LVN) 1 documented medication administration accurately for one of 18 sampled residents (Resident 56), in accordance with professional standards.

This failure had the potential to delay Resident 56 in reaching her care goals due to the documentation of medication that was not given.

Findings:

During a review of Resident 56's Admission Record, the Admission Record indicated Resident 56 was originally admitted to the facility on [DATE REDACTED] and was most recently readmitted on [DATE REDACTED]. Resident 56's admitting diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior).

During a review of Resident 56's Minimum Data Set (MDS, a resident assessment tool), dated 11/13/2024,

the MDS indicated Resident 56 did not have cognitive impairments (problems with thinking, learning, or memory). The MDS indicated Resident 56 was independent to eat, and independent with mobility.

During a review of Resident 56's physician order, dated 10/14/2024, the order indicated Resident 56 was to receive 0.25 milligrams (mg, a unit of measuring medication dosage) of Ozempic (a prescription injectable medication used to treat type 2 diabetes mellitus [a disorder characterized by difficulty in blood sugar control and poor wound healing] in adults) in the morning every 7 days.

During a review of Resident 56's Medication Administration Record (MAR), dated 2/1/2025 to 2/28/2025, the MAR indicated Resident 56 received scheduled weekly doses of Ozempic on 2/4/2025 and 2/11/2025.

During a concurrent observation and interview, on 2/12/2025 at 11:36 a.m., of the South Station Medication Cart, with LVN 2 Resident 56's Ozempic injection pen was observed. LVN 2 stated the Ozempic injection pen was opened 11/5/2024 and stated the injection pen was empty.

During a concurrent observation and interview, on 2/12/2025 at 11:39 a.m., of the South Station Medication fridge, with LVN 2, a sealed and unopened Ozempic injection pen was observed. LVN 2 stated the Ozempic injection pen belonged to Resident 56 and was sealed and unused.

During a concurrent observation and interview, on 2/12/2025 at 1:04 p.m., of the South Station Medication Cart, with LVN 1, Resident 56's Ozempic injection pen was observed. LVN 1 stated the Ozempic injection pen in the cart was opened 2/12/2025 but was dated as opened on 2/11/2025. LVN 1 stated she administered Resident 56's Ozempic dose on 2/12/2025 (1 day after the scheduled dose). LVN 1 stated Resident 56 originally refused the medication, then changed her mind and later agreed to receive the scheduled dose. LVN 1 stated she forgot to administer the dose after Resident 56 changed her mind.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 48 056417 Department of Health & Human Services Printed: 09/08/2025 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 056417 B. Wing 02/14/2025

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

View Heights Conv Hosp 12619 S. Avalon Blvd Los Angeles, CA 90061

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

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

F 0658 During a concurrent interview and record review, on 2/12/2025 at 1:07 p.m., with LVN 1, Resident 56's MAR dated 2/1/2025 to 2/28/2025 was reviewed. LVN 1 stated the MAR indicated Resident 56's Ozempic dose Level of Harm - Minimal harm or was ordered for and documented as administered on 2/11/2025. LVN 1 stated Resident 56's Ozempic dose, potential for actual harm scheduled for 2/11/2025, was administered on 2/12/2025. LVN 1 stated medications should not be documented as administered until they are given. Residents Affected - Few

During an interview on 2/13/2025 at 11:54 a.m., with the Director of Nursing (DON), the DON stated licensed nursing staff were to document administration of medications on the MAR right after the medication is administered. The DON stated medications should not be documented as administered before they are given.

During a review of the facility policy and procedure (P&P) titled Documentation of Medication Administration, dated 2024, the P&P indicated documentation of medication administration was to be done at the time medications are given.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 48 056417 Department of Health & Human Services Printed: 09/08/2025 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 056417 B. Wing 02/14/2025

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

View Heights Conv Hosp 12619 S. Avalon Blvd Los Angeles, CA 90061

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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47679 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure quality of care was provided Residents Affected - Few for two of three sampled residents (Residents 31 and 16) by failing to:

1. Clarify the monitoring of Resident 31's blood glucose (amount of sugar in the blood) prior to the administration of Insulin Glargine (a hormone that removes excess sugar from the blood, can be produced by

the body or given artificially via medication).

This deficient practice resulted in Resident 31's blood glucose being unmonitored prior to being administered Insulin Glargine on 2/8/2025, 2/9/2025, 2/10/2025, 2/11/2025, and 2/12/2025. This deficient practice also had

the potential to result in Resident 31 becoming hypoglycemic (a condition when the blood sugar level drops too low) and symptomatic with dizziness, shakiness, and confusion.

2. Implement Resident 16's physician order for wound treatment to the right scalp.

This deficient practice had the potential to increase the risk of infection for Resident 16, and placed the resident at risk for fever, pain, and worsening skin condition.

Findings:

1. During a review of Resident 31's Admission Record (Face Sheet), the Face Sheet indicated Resident 31 was initially admitted to the facility on [DATE REDACTED] and readmitted to the facility on [DATE REDACTED] with diagnoses that included schizophrenia (a mental illness that is characterized by disturbances in thought), type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and hyperlipidemia (a condition with too many fats in the blood).

During a review of Resident 31's Minimum Data Set ([MDS], a resident assessment tool), dated 11/29/2024,

the MDS indicated Resident 31's cognition (process of thinking) was moderately impaired. The MDS indicated Resident 31 was independent with eating, toileting, bathing, and dressing. The MDS indicated Resident 31 was receiving hypoglycemic medication (medication used to lower blood sugar levels).

During a review of Resident 31's Order Recap Report, dated 2/1/2024 through 2/28/2025, the Order Recap indicated to:

a. Inject Insulin Glargine (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) 24 units (unit of measurement), subcutaneously (in the fat tissue), in

the morning, related to type 2 diabetes mellitus. The order recap indicated the order was started 1/6/2023 and discontinued on 2/7/2025.

b. Inject Insulin Glargine 12 units, subcutaneously, in the morning, for type 2 diabetes mellitus. The order recap indicated the order was started 2/8/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 48 056417 Department of Health & Human Services Printed: 09/08/2025 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 056417 B. Wing 02/14/2025

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

View Heights Conv Hosp 12619 S. Avalon Blvd Los Angeles, CA 90061

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 0684 During an interview on 2/13/2025 at 11:08 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated prior to administering Insulin Glargine to a resident, the licensed nurse was responsible for checking the resident's Level of Harm - Minimal harm or blood glucose. LVN 1 stated after checking the resident's blood glucose, Insulin Glargine would immediately potential for actual harm be administered.

Residents Affected - Few During a concurrent interview and record review on 2/13/2025 at 11:10 a.m., with LVN 1, Resident 31's Medication Administration Record ([MAR], a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 2/1/2025 through 2/28/2025, was reviewed. LVN 1 stated Resident 31's order for Insulin Glargine was decreased from 24 units to 12 units on 2/8/2025. LVN 1 stated the MAR did not prompt LVN 1 to check Resident 31's blood glucose, on 2/8/2025, 2/9/2025, 2/10/2025, 2/11/2025, and 2/12/2025, prior to administering 12 units of Insulin Glargine. LVN 1 stated when Resident 31's Insulin Glargine order was changed, the option to check Resident 31's blood glucose was not included. LVN 1 stated when Resident 31 was receiving 24 units of Insulin Glargine, the MAR always prompted the licensed nurse to check Resident 31's blood glucose level. LVN 1 stated she was confused why Resident 31's order did not include blood glucose monitoring.

During a concurrent interview and record review on 2/13/2025 at 11:15 a.m., with LVN 1, Resident 31's Blood Sugars, dated 2/1/2025 through 2/13/2025 were reviewed. LVN 1 stated Resident 31's Insulin Glargine was scheduled for administration at 8 a.m. LVN 1 stated the Blood Sugars did not indicate Resident 31's blood glucose was checked on 2/8/2025, 2/9/2025, 2/10/2025, 2/11/2025, and 2/12/2025 between 7 a. m. and 9 a.m.

During an interview on 2/13/2025 at 11:18 a.m., with LVN 1, LVN 1 stated Resident 31's order for Insulin Glargine should have been clarified with Resident 31's physician because the order did not include blood glucose monitoring prior to administering Insulin Glargine. LVN 1 stated Resident 31's order for Insulin Glargine should have been clarified on 2/8/2025 prior to the first administration. LVN 1 stated Insulin Glargine affected Resident 31's blood glucose over a long period of time, however, checking Resident 31's blood glucose on administration was still important. LVN 1 stated if Resident 31's blood glucose was low (normal blood glucose level between 70 milligrams [mg, unit of measurement] per deciliter [dL, unit of measurement] [mg/dL] and 100 mg/dL), administering medication that decreased blood glucose could be very harmful. LVN 1 stated Resident 31 could experience hypoglycemic symptoms such as shakiness, dizziness, and confusion.

During a review of the facility's policy and procedure (P&P) titled, Insulin Administration, revised 10/2019, the P&P indicated, [The purpose of the policy is to] provide guidelines for the safe administration of insulin to residents with diabetes . The nurse shall notify the Director of Nursing Services and Attending Physician of any discrepancies, before giving the insulin.

During a review of the facility's P&P titled, Physician's (Prescriber's) Orders, revised 12/2022, the P&P indicated, Incomplete, unreadable, ambiguous, or confusing orders will be clarified with the prescriber prior to medication administration by the nurse or prior to pharmacy dispensing.

49900

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 48 056417 Department of Health & Human Services Printed: 09/08/2025 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 056417 B. Wing 02/14/2025

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

View Heights Conv Hosp 12619 S. Avalon Blvd Los Angeles, CA 90061

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 0684 2. During a review of Resident 16's Admission Record, the Admission Record indicated Resident 16 was admitted to the facility on [DATE REDACTED]. Resident 16's diagnoses included schizoaffective disorder (a mental Level of Harm - Minimal harm or illness that could affect thoughts, mood, and behavior), diabetes mellitus (DM- a disorder characterized by potential for actual harm difficulty in blood sugar control and poor wound healing), hypertension (HTN-high blood pressure), and gastroesophageal reflux disease (GERD, a chronic condition that occurred when stomach contents leak into Residents Affected - Few the esophagus [the muscular tube through which food passed from the throat to the stomach]). The Admission Record indicated Resident 16 had a public guardian (responsible for the care of individuals who were no longer able to make decisions or care for themselves).

During a review of Resident 16's MDS, dated [DATE REDACTED], the MDS indicated Resident 16 had intact cognitive skills for daily decision making. The MDS indicated Resident 16 was independent with eating, toileting hygiene, showering/bathing self, chair/bed-to-chair transfer, and walking. The MDS indicated Resident 16 required setup assistance with oral hygiene and personal hygiene. The MDS indicated Resident 16 had hallucinations (a false perception of a sight, sound, smell, taste, or touch that seems real but was not), delusion (having false or unrealistic beliefs), and disorganized thinking (a symptom of some mental health disorders that made it difficult to think clearly and logically).

During a review of Resident 16's Admission Screening/History, dated 2/11/2025, the form indicated Resident 16 was readmitted to facility with diagnosis of closed head injury and scalp laceration (deep cut). The form indicated Resident 16 had four staples to the right side of the scalp.

During a review of Resident 16's physician order, dated 2/11/2025, the order indicated staff were to cleanse

the wound with soap and water daily.

During a review of Resident 16's care plan titled Has head injury with scalp laceration, initiated on 2/11/2025,

the care plan indicated the goal was for Resident 16 to remain free of infection. The care plan interventions indicated to assess Resident 16 every shift for any signs of infection.

During a concurrent observation and interview on 2/12/2025 at 8:29 a.m. with Resident 16, in Resident 16's room, Resident 16's right scalp was observed with dried blood and four staples. Resident 16 stated he fell on [DATE REDACTED]. Resident 16 stated since his fall no staff had cleansed his scalp. Resident 16 stated his right scalp was only cleansed in the hospital before placing the staples.

During a concurrent observation and interview on 2/13/2025 at 10:36 a.m. with Resident 16, in Resident 16's room, Resident 16's right scalp was observed with dried blood and four staples. Resident 16 stated no staff cleansed his scalp.

During a concurrent record review and interview on 2/13/2025 at 11:08 a.m. with LVN 4, Resident 16's MAR, dated from 2/1/2025 to 2/28/2025, was reviewed. LVN 4 stated the physician order to cleanse Resident 16's wound was not transcribed to the MAR. LVN 4 stated the order should be on the MAR. LVN 4 stated Resident 16 might have an infection, fever, headache, and pain if the wound was not cleansed per the order.

During an interview on 2/13/2025 at 3:06 p.m. with the Infection Preventionist Nurse (IPN), the IPN stated Resident 16 had the potential for an infection, pain, and swelling if the wound was not cleansed according to

the physician order.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 48 056417 Department of Health & Human Services Printed: 09/08/2025 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 056417 B. Wing 02/14/2025

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

View Heights Conv Hosp 12619 S. Avalon Blvd Los Angeles, CA 90061

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 0684 During a review of the facility's P&P, titled Physician (Prescriber's) Orders, approved in 1/2023, the P&P indicated The order will be added to the Medication Administration record or Treatment record. For those Level of Harm - Minimal harm or facilities with Electronic Medical Records (EMR), the noting and transcription will be done electronically. potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 48 056417 Department of Health & Human Services Printed: 09/08/2025 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 056417 B. Wing 02/14/2025

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

View Heights Conv Hosp 12619 S. Avalon Blvd Los Angeles, CA 90061

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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49900

Residents Affected - Few Based on observation, interview, and record review, the facility failed to conduct an Interdisciplinary Care Team (IDT, a group of healthcare professionals who worked together to provide care for residents in a nursing home) conference after a witnessed fall on 12/19/2024 for one of seven residents (Resident 112).

This deficient practice had the potential to increase the possibility of recurrent falls for Resident 112.

Findings:

During a review of Resident 112's Admission Record, the Admission Record indicated Resident 112 was admitted to the facility on [DATE REDACTED]. Resident 112's diagnoses included schizophrenia (a mental illness that was characterized by disturbances in thought), insomnia (trouble falling asleep or staying asleep), and Post-Traumatic Stress Disorder (PTSD - a disorder in which a person had difficulty recovering after experiencing or witnessing a traumatic event). The Admission Record indicated Resident 112 had a public guardian (responsible for the care of individuals who were no longer able to make decisions or care for themselves).

During a review of Resident 112's MDS, dated [DATE REDACTED], the MDS indicated Resident 112 had intact cognitive skills for daily decision making (ability to think, remember and reason). The MDS indicated Resident 112 was independent (resident completed the activity by himself without assistance from a helper) with eating, toileting hygiene, showering/bathing self, and all mobility while in and out of bed. The MDS indicated Resident 112 required setup assistance with oral hygiene and personal hygiene. The MDS indicated Resident 112 experienced hallucinations (a false perception of a sight, sound, smell, taste, or touch that seems real but was not), delusions (having false or unrealistic beliefs), and disorganized thinking (a symptom of some mental health disorders that made it difficult to think clearly and logically). The MDS indicated Resident 112 reported it was very important to have family or a close friend involved in discussions about Resident 112's care while in the facility.

During a review of Resident 112's Change in Condition (COC) Evaluation form, dated 12/19/2024, the COC indicated on 12/19/2024 at approximately 7:45 a.m., Resident 112 had a witnessed fall while walking to the dining room for breakfast because he lost balance.

During a concurrent record review and interview on 2/14/2025 at 8:45 a.m. with the DON, Resident 112's IDT records, dated from 7/7/2024 to 12/31/2024, was reviewed. The DON stated there was no IDT conference conducted for the fall on 12/19/2024. The DON stated the facility conducted an IDT conference to find out what exactly happened to the resident, the cause of the incident, and the contributing factors to the incident.

The DON stated the IDT normally happened within 7 days of an incident to prevent recurrence of the incident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 48 056417 Department of Health & Human Services Printed: 09/08/2025 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 056417 B. Wing 02/14/2025

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

View Heights Conv Hosp 12619 S. Avalon Blvd Los Angeles, CA 90061

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 0689 During a concurrent record review and interview on 2/14/2025 at 8:45 a.m. with the DON, the facility's Policy & Procedure (P&P), titled Fall Management System, approved in 4/2023, was reviewed. The P&P indicated Level of Harm - Minimal harm or When a resident sustains a fall . The investigation and appropriate interventions will be initiated at the time of potential for actual harm the fall and reviewed by Nursing Management following the next morning stand-up meeting and QA (quality assurance, a system that evaluated and improved patient care) Meeting. The DON stated facility did not Residents Affected - Few have a specific policy stating when the IDT conference should conduct after a fall, but the QA meeting included the IDT team and was held quarterly and should address Resident 112's fall on 12/19/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 48 056417 Department of Health & Human Services Printed: 09/08/2025 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 056417 B. Wing 02/14/2025

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

View Heights Conv Hosp 12619 S. Avalon Blvd Los Angeles, CA 90061

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

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

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47286

Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure medications were administered as ordered for two of 18 sampled residents (Resident 56 and Resident 49) when:

1. Licensed Vocational Nurse (LVN) 1 administered five doses of Ozempic (a prescription injectable medication used to treat type 2 diabetes mellitus [DM, a disorder characterized by difficulty in blood sugar control and poor wound healing] in adults) to Resident 56 from an Ozempic injection pen that was 35 days beyond its use by date.

2. LVN 1 administered Metformin (a medication used to treat high blood sugar levels caused by DM) to Resident 49 greater than one hour before the scheduled administration time.

These failures created the potential for Resident 56 to not achieve the desired weight loss the Ozempic was indicated for, due to decreased effectiveness of the expired medication.

These failures also created the potential for Resident 49 to sustain gastric distress (a group of uncomfortable symptoms related to the digestive system, typically characterized by abdominal pain, nausea, vomiting, and/or diarrhea) related to the administration of Metformin on an empty stomach.

Findings:

1. During a review of Resident 56's Admission Record, the Admission Record indicated Resident 56 was originally admitted to the facility on [DATE REDACTED] and was most recently readmitted on [DATE REDACTED]. Resident 56's admitting diagnoses included obesity (a chronic condition characterized by an excessive accumulation of body fat).

During a review of Resident 56's Minimum Data Set (MDS, a resident assessment tool), dated [DATE REDACTED], the MDS indicated Resident 56 did not have cognitive impairments (problems with thinking, learning, or memory). The MDS indicated Resident 56 was independent to eat, and independent with mobility.

During a review of Resident 56's physician order, dated [DATE REDACTED], the order indicated Resident 56 was to receive 0.25 milligrams (mg, a unit of measuring medication dosage) of Ozempic every seven days for obesity.

During a concurrent observation and interview, on [DATE REDACTED] at 11:36 a.m., of the North Station Medication Cart, with LVN 2, Resident 56's Ozempic injection pen was observed. LVN 2 stated the Ozempic injection pen was opened [DATE REDACTED] and stated the injection pen was empty. LVN 2 stated the Ozempic injection pen originally contained enough medication for eight administrations. LVN 2 stated there were no other Ozempic injection pens indicated for Resident 56 in the cart.

During a concurrent observation and interview on [DATE REDACTED] at 11:39 a.m., of the North Station medication storage room refrigerator, with LVN 2, a sealed Ozempic injection pen was observed. LVN 2 stated the Ozempic injection pen belonged to Resident 56 and had not been opened or used.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 48 056417 Department of Health & Human Services Printed: 09/08/2025 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 056417 B. Wing 02/14/2025

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

View Heights Conv Hosp 12619 S. Avalon Blvd Los Angeles, CA 90061

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

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

F 0755 During a concurrent observation and interview, on [DATE REDACTED] at 1:04 p.m., with LVN 1, Resident 56's Ozempic injection pen, with open date [DATE REDACTED], was observed. LVN 1 stated the packaging indicated the injection pen Level of Harm - Minimal harm or was to be discarded 56 days after opening. LVN 1 stated the injection pen was opened on [DATE REDACTED], and the potential for actual harm injection pen should have been discarded on [DATE REDACTED]. LVN 2 stated she used Resident 56's new Ozempic injection pen from the South Station refrigerator to administer Resident 56's Ozempic dose on [DATE REDACTED]. Residents Affected - Few

During a review of Resident 56's MAR, dated [DATE REDACTED] to [DATE REDACTED], the MAR indicated Resident 56 received four administrations of Ozempic on [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], and [DATE REDACTED] from the expired Ozempic injection pen opened [DATE REDACTED].

During a review of Resident 56's MAR, dated [DATE REDACTED] to [DATE REDACTED], the MAR indicated Resident 56 received one administration of Ozempic on [DATE REDACTED] from the expired Ozempic injection pen opened [DATE REDACTED].

During an interview on [DATE REDACTED] at 11:54 a.m., with the Director of Nursing (DON), the DON stated the Ozempic injection pen, including any unused doses, were to be discarded after 56 days. The DON stated licensed nursing staff should not administer medication from an injection pen past its use by date. The DON stated a new injection pen should be opened and used. The DON stated using an Ozempic injection pen beyond its use by date created the potential for complications. The DON stated the medication could have lost its potency (the intensity of effect produced for a given drug dose). The DON stated Resident 56's Ozempic was indicated for obesity, and stated administration of Ozempic beyond its use by date could result

in Resident 56 not having the desired outcome of weight loss.

2. During a review of Resident 49's Admission Record, the Admission Record indicated Resident 49 was admitted on [DATE REDACTED]. Resident 49's admitting diagnoses included DM.

During a review of Resident 49's MDS, dated [DATE REDACTED], the MDS indicated Resident 49 did not have cognitive impairments. The MDS indicated Resident 49 was independent to eat, and independent with mobility.

During a review of Resident 49's physician order, dated [DATE REDACTED], the order indicated Resident 49 was to receive 1000 mg of Metformin two times a day with meals or immediately after meals.

During a review of Resident 49's MAR, dated [DATE REDACTED] to [DATE REDACTED], the MAR indicated Resident 49 was to receive two scheduled Metformin doses at 8:00 a.m. and 6:00 p.m. every day.

During an observation on [DATE REDACTED] at 4:25 p.m., at the North Nurse's Station, LVN 1 was observed administering 1000 mg of Metformin to Resident 49. Resident 49 took the medication with a cup of water.

During an interview on [DATE REDACTED] a 9:49 a.m., with the DON, the DON stated medications were to be administered at the ordered time but could also be administered up to one hour before or one hour after the ordered time. The DON stated the earliest time Resident 49's scheduled 6:00 p.m. Metformin dose could be administered was 5:00 p.m. The DON stated the Metformin administration on [DATE REDACTED], at 4:25 p.m., was too early and not acceptable. The DON stated dinner was not served until 5:00 p.m., and the Metformin should have been administered at 5:00 p.m. with dinner, or immediately after Resident 49 ate dinner. The DON stated administration of Metformin with an empty stomach could cause avoidable gastric distress.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 48 056417 Department of Health & Human Services Printed: 09/08/2025 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 056417 B. Wing 02/14/2025

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

View Heights Conv Hosp 12619 S. Avalon Blvd Los Angeles, CA 90061

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

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

F 0755 During a review of the facility's job description for a LVN, titled Charge Nurse Job Description, undated, the job description indicated LVNs were to prepare and administer medications as ordered by the physician. The Level of Harm - Minimal harm or job description also indicated LVNs were to dispose of drugs as required, and in accordance with established potential for actual harm procedures.

Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled Administration of Medications - Medication Pass, dated ,d+[DATE REDACTED], the P&P indicated medications could be administered up to one (1) hour before or up to one (1) hour after the designated administration time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 48 056417 Department of Health & Human Services Printed: 09/08/2025 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 056417 B. Wing 02/14/2025

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

View Heights Conv Hosp 12619 S. Avalon Blvd Los Angeles, CA 90061

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 0758 Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic Level of Harm - Minimal harm or medications are only used when the medication is necessary and PRN use is limited. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47286 Residents Affected - Few 47679

Based on interview and record review, the facility failed to ensure two of five sampled residents (Resident 3 and Resident 31) were free from unnecessary medications when:

1. Staff failed to monitor for the presence of self-isolating behaviors for Resident 3, and ensure a gradual dose reduction (GDR, stepwise tapering of a medication dose) was attempted for her Cymbalta (a medication used to treat depression and anxiety), which was initiated in March 2024.

2. Staff failed to provide behavior manifestations for hallucinations of Resident 31's use of haloperidol (an antipsychotic medication [a medication that affects the mind, emotions, and behavior]).

These deficient practices had the potential for Resident 3 to suffer unwanted adverse effects from continued administration of Cymbalta including excessive sedation, heart problems, and tremors (involuntary, rhythmic shaking movements that can affect various parts of the body, such as the hands, arms, legs, head, or voice), resulted in the facility indicating the use of haloperidol to treat only Resident 31's diagnosis and not behaviors of schizophrenia (a mental illness that is characterized by disturbances in thought) and had the potential to result in the licensed nurses being to monitor Resident 31's behaviors related to schizophrenia.

Findings:

1. During a review of Resident 3's Admission Record (Face Sheet), the Face Sheet indicated Resident 3 was admitted to the facility on [DATE REDACTED]. Resident 3's admitting diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). Resident 3 did not have diagnoses of depression or anxiety.

During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 12/15/2024,

the MDS indicated Resident 3 did not have cognitive impairments (problems with thinking, learning, or memory). The MDS indicated Resident 3 did not exhibit physical or verbal behaviors (e.g., physical aggression towards others and/or verbal aggression/threats towards others). The MDS indicated Resident 3 did not reject care. The MDS indicated Resident 3 was independent with most activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) and mobility while in and out of bed.

During a review of Resident 3's physician orders, dated 3/21/2024, the order indicated Resident 3 was to receive Cymbalta 30 milligrams (mg, a unit of dose measurement) every morning for depression manifested by self-isolative behavior.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 48 056417 Department of Health & Human Services Printed: 09/08/2025 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 056417 B. Wing 02/14/2025

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

View Heights Conv Hosp 12619 S. Avalon Blvd Los Angeles, CA 90061

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 0758 During a review of Resident 3's Psychotropic Monthly Summary assessments, dated 6/1/2024, 9/2/2024, 12/1/2024, and 1/2/2025, the assessments indicated Resident 3 was assessed for her use of Cymbalta for Level of Harm - Minimal harm or depression, for the previous months. The assessments indicated Resident 3 did not exhibit any depression potential for actual harm for the months of 5/2024, 8/2024, 11/2024.

Residents Affected - Few During a review of Resident 3's Psychotropic Monthly Summary assessments, there were no documented assessments for the months of 3/2024, 4/2024, 7/2024, 9/2024, or 10/2024.

During a concurrent interview and record review, on 2/13/2025 at 11:23 a.m., with the Director of Nursing (DON), Resident 3's physician orders and Psychotropic Monthly Summaries dated 3/2024 to current, were reviewed. The DON stated the Psychotropic Monthly Summaries were based on the resident's behaviors from the prior month, and stated it was based on monitoring conducted by staff. The DON stated there was no documentation in Resident 3's electronic medical record (EMR) that indicated staff were monitoring Resident 3 for depression or self-isolation. The DON stated the current documentation present in Resident 3's EMR indicated she was participating in group meetings and activities and was not displaying self-isolative behaviors, and did not indicate a continued need for Cymbalta. The DON stated if the behavior the medication was ordered for was not present, a GDR should be completed to ensure the medication was discontinued if no longer needed. The DON stated a GDR had not been attempted since Resident 3's Cymbalta was started in 3/2024. The DON stated that prolonged administration of Cymbalta, if no longer indicated, could cause Resident 3 to experience unwanted side effects including excessive sedation, heart problems, and tremors.

During a review of the facility's policy and procedure (P&P) titled Psychotropic Medication Use, dated 12/2024, the P&P indicated all ordered psychotropic medications (drugs that alter mood, thoughts, emotions, and behavior) were to be used to treat behaviors, and there must be a clinical indication. The P&P indicated

the psychotropic medication should be used at the lowest dose possible to achieve the desired effect. The P&P indicated all residents on psychotropic medications were to be monitored for their efficacy. The P&P indicated staff were to monitor the resident's behavior for residents receiving psychotropic medications.

2. During a review of Resident 31's Face Sheet, the Face Sheet indicated Resident 31 was initially admitted to the facility on [DATE REDACTED] and readmitted to the facility on [DATE REDACTED] with diagnoses that included schizophrenia, type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and hyperlipidemia (a condition with too many fats in the blood).

During a review of Resident 31's MDS, dated [DATE REDACTED], the MDS indicated Resident 31's cognition (process of thinking) was moderately impaired. The MDS indicated Resident 31 had hallucinations (when an individual sees, hears, smells, tastes, or feels something that is not there) and delusions (an unshakable belief in something that is untrue). The MDS indicated Resident 31 was independent with eating, toileting, bathing, and dressing. The MDS indicated Resident 31 took an antipsychotic medication.

During a review of Resident 31's Medication Review Report dated 2/1/2025 through 2/28/2025, the Medication Review Report indicated to inject haloperidol 450 mg, intramuscularly (into the muscle) every four weeks on Thursday, on the day shift for schizophrenia.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 48 056417 Department of Health & Human Services Printed: 09/08/2025 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 056417 B. Wing 02/14/2025

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

View Heights Conv Hosp 12619 S. Avalon Blvd Los Angeles, CA 90061

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 0758 During an interview on 2/13/2025 at 2:36 p.m., with Registered Nurse (RN) 1, RN 1 stated the resident's physician was responsible for providing the indication of use of the psychotropic medications. RN 1 stated Level of Harm - Minimal harm or indicating the manifested behaviors was important, so the licensed nurses were aware of the behaviors the potential for actual harm resident was being treated for. RN 1 stated Resident 31 was treated with haloperidol but without the behavior manifested indicated, it seemed Resident 31 was being treated solely for having schizophrenia, which was Residents Affected - Few not appropriate. RN 1 stated the order should have been clarified over the years with Resident 31's physician so the licensed nurses could better monitor and care for Resident 31.

During an interview on 2/13/2025 at 4:08 p.m., with the DON, the DON stated psychotropic medication were used to treat specific behaviors and symptoms manifested by a diagnosis. The DON stated a diagnosis alone was not an appropriate indication to administer psychotropic medication. The DON stated Resident 31's order for haloperidol was active since 1/4/2018 and was not clarified since then. The DON stated although Resident 31 had manifested behaviors due to his schizophrenia, those specific behaviors were not indicated on the order. The DON stated it was important to clarify the manifested behaviors that were being treated, so the licensed nurses were aware of the specific behaviors and to be able to assess if the medication treatment was effective.

During a review of the facility's P&P titled, Psychotropic Medication Use, revised 10/2019, the P&P indicated, Psychotropic medications to treat behaviors will be used appropriately to address specific underlying or psychiatric causes of behavioral symptoms . All medications used to treat behaviors must have clinical indication and be used in the lowest possible doses to achieve the desired therapeutic effect.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 48 056417 Department of Health & Human Services Printed: 09/08/2025 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 056417 B. Wing 02/14/2025

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

View Heights Conv Hosp 12619 S. Avalon Blvd Los Angeles, CA 90061

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 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47286 Residents Affected - Few Based on observation, interview, and record review, the facility failed to dispose of medication for one of 18 sampled residents (Resident 56) when:

1. An Ozempic (a prescription injectable medication used to treat type 2 diabetes mellitus [DM, a disorder characterized by difficulty in blood sugar control and poor wound healing] in adults) injection pen was kept in

the North Station medication cart beyond its use-by date of 12/31/2024.

2. Licensed Vocational Nurse (LVN) 1 failed to label an Ozempic injection pen with the correct open date.

These failures created the potential for Resident 56 to receive Ozempic with reduced potency and effectiveness, possibly causing a delay in the effectiveness of the ordered therapy.

Findings:

During a review of Resident 56's Admission Record, the Admission Record indicated Resident 56 was originally admitted to the facility on [DATE REDACTED] and was most recently readmitted on [DATE REDACTED]. Resident 56's admitting diagnoses included obesity (a chronic condition characterized by an excessive accumulation of body fat).

During a review of Resident 56's Minimum Data Set (MDS, a resident assessment tool), dated 11/13/2024,

the MDS indicated Resident 56 did not have cognitive impairments (problems with thinking, learning, or memory). The MDS indicated Resident 56 was independent to eat, and independent with mobility.

During a review of Resident 56's physician order, dated 10/14/2024, the order indicated Resident 56 was to receive 0.25 milligrams (mg, a unit of measuring medication dosage) of Ozempic every seven days for obesity.

During a concurrent observation and interview, on 2/12/2025 at 11:36 a.m., of the North Station Medication Cart, with LVN 2, Resident 56's Ozempic injection pen was observed. LVN 2 stated the Ozempic injection pen was opened 11/5/2024 and stated the injection pen was empty. LVN 2 stated the Ozempic injection pen originally contained enough medication for eight administrations. LVN 2 stated there were no other Ozempic injection pens indicated for Resident 56 in the cart.

During a concurrent observation and interview on 2/12/2025 at 11:39 a.m., of the North Station medication storage room refrigerator, with LVN 2, a sealed Ozempic injection pen was observed. LVN 2 stated the Ozempic injection pen belonged to Resident 56 and had not been opened or used.

During a review of Resident 56's Medication Administration Records (MAR), dated 1/1/2025 to 1/31/2025 and 2/1/2025 to 2/28/2025, the MARs indicated Resident 56 received a total of five doses of Ozempic from

the Ozempic injection pen opened 11/5/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 48 056417 Department of Health & Human Services Printed: 09/08/2025 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 056417 B. Wing 02/14/2025

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

View Heights Conv Hosp 12619 S. Avalon Blvd Los Angeles, CA 90061

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 0761 During a concurrent observation and interview, on 2/12/2025 at 1:04 p.m., with LVN 1, Resident 56's Ozempic injection pens, with open dates of 11/5/2024 and 2/11/2025, were observed. LVN 1 stated the Level of Harm - Minimal harm or packaging indicated the injection pens were to be discarded 56 days after opening. LVN 1 stated the potential for actual harm injection pen opened on 11/5/2024 should have been discarded on 12/31/2024. LVN 1 stated the Ozempic injection pen dated 2/11/2025 was opened on 2/12/2025. LVN 1 stated the open date should be accurate Residents Affected - Few and the open date of 2/11/2025 was not correct.

During an interview on 2/13/2025 at 11:54 a.m., with the Director of Nursing (DON), the DON stated the Ozempic injection pen, including any unused doses, were to be discarded after 56 days. The DON stated licensed nursing staff should not administer medication from an injection pen past its use by date. The DON stated a new injection pen should be opened and used. The DON stated the medication could have lost its potency (the intensity of effect produced for a given drug dose). The DON stated Resident 56's Ozempic was indicated for obesity, and stated administration of Ozempic beyond its use by date could result in Resident 56 not having the desired outcome of weight loss.

During a review of the facility's job description for a LVN, titled Charge Nurse Job Description, undated, the job description indicated LVNs were to dispose of drugs as required, and in accordance with established procedures.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 48 056417 Department of Health & Human Services Printed: 09/08/2025 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 056417 B. Wing 02/14/2025

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

View Heights Conv Hosp 12619 S. Avalon Blvd Los Angeles, CA 90061

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 0800 Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Level of Harm - Minimal harm or potential for actual harm 45009

Residents Affected - Many Based on observation, interview and record review, the facility did not provide a diet that met the nutritional needs for all facility residents by:

1. Not ensuring residents received a breakfast that offered a nutritional value.

2. Not ensuring a system was in place to ensure meal substitutes and alternatives provided were of equal or nutritive value for all facility residents.

These deficient practices had the potential to impact resident's nutritional status and could result in all residents sustaining undesired weight loss and malnutrition.

Findings:

1. During an observation on 2/13/2025 at 7:11 a.m. in the kitchen, a mc muffin sandwich without meat was served to the residents. The mc muffin sandwich contained only scrambled eggs.

During an interview on 2/13/2025 at 7:20 a.m. with Dietary Supervisor (DS), the DS stated they were serving

a vegetarian mc muffin sandwich for breakfast. The DS stated the mc muffin sandwich did not come with meat and that made it a vegetarian sandwich.

During an interview on 2/13/2025 at 7:39 a.m. with Dietary [NAME] (DC) 2, DC 2 stated she was a serving a sandwich with scrambled eggs for breakfast. DC 2 stated the sandwich was supposed to have sausage but

she did not have any sausage in the kitchen. DC 2 stated this had happened before where the kitchen did not have any sausage for resident meals. DC 2 stated it was important to serve residents a meal that provided a nutritious value.

During a concurrent interview and record review on 2/13/2025 at 8:36 a.m. with DS, Cooks Spreadsheet, dated 2/13/2025 was reviewed. The [NAME] Spreadsheet indicated residents had to receive a mc muffin sandwich with sausage meat. DS stated she did not know the sandwich had to have meat. The DS stated

she was supposed to check on the food that was served to the residents but she did not. The DS stated she did not notice the mc muffin sandwiches did not have sausage. The DS stated it was important to provide all residents with the correct nutrition to prevent weight loss.

2. During a concurrent interview and record review, on 2/12/2025 at 1:27 p.m., with the Registered Dietician (RD), the facility document titled Nutritional Breakdown, dated Winter 2024 to 2025, was reviewed. The RD stated the document provided nutritional data for various diets (i.e., regular [no modifications], vegetarian, low-fat, etc.), but did not indicate the nutritional data for any specific menu items, including those being served to facility residents. The RD stated she would need to check if the facility had a nutritional analysis available that provided nutritional data for the menus being served in the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 48 056417 Department of Health & Human Services Printed: 09/08/2025 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 056417 B. Wing 02/14/2025

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

View Heights Conv Hosp 12619 S. Avalon Blvd Los Angeles, CA 90061

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 0800 During an interview on 2/12/2025 at 2:10 p.m., with the RD, the RD stated the facility did not have a system

in place to determine the nutritional values for the menus provided to facility residents. The RD stated every Level of Harm - Minimal harm or meal served had unique nutrient content, with varying levels of protein, calories, fats, and other key nutrients. potential for actual harm The RD stated kitchen staff were to notify her if a resident was refusing the provided meal, and she was responsible for determining if the alternative or substitute being offered was of similar or equal nutritive value. Residents Affected - Many The RD stated there was no system in place to allow her to do that. The RD stated the alternatives provided to residents included peanut butter sandwiches, grilled cheese sandwiches, or a chef's salad. The RD stated

she could not state the nutritional content of those items, or if their nutritional content was sufficient to replace the planned menu items. The RD stated all residents had daily nutritional needs and stated that she was responsible to ensure those needs were met. The RD stated an inability to identify the nutritional content of the planned menu, and the alternatives, created the potential for residents to sustain malnourishment and loss of muscle mass.

During an interview on 2/14/2025 at 9:24 a.m., with the Director of Nursing (DON), the DON stated all meals provided in the facility should be sufficient in meeting the residents' nutritional needs. The DON stated that if nutritional needs were not met, it placed residents at for undesired weight loss.

During a review of facility's Policy and Procedure (P&P) titled Menu Planning, dated 2020, the P&P indicated menus are planned to meet nutritional needs of residents in accordance with national guidelines

During a review of the facility's P&P titled Daily Food Menu Alternative, dated 2020, the P&P indicated residents were to be provided a suitable, nourishing alternate meal after the planned, served meal has been refused.

47286

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 48 056417 Department of Health & Human Services Printed: 09/08/2025 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 056417 B. Wing 02/14/2025

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

View Heights Conv Hosp 12619 S. Avalon Blvd Los Angeles, CA 90061

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 0801 Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Level of Harm - Minimal harm or potential for actual harm 45009

Residents Affected - Many Based on interview and record review, the facility failed to employ a dietary supervisor (DS) that met the qualifications of having an associate's degree or higher in food service management or in hospitality, was a certified dietary manager, certified food service manager or had national certification for food service management and safety.

This deficient practice had the potential to affect 146 residents residing in the facility by potentially not receiving the nutritional assistance and guidance they needed to attain their highest practicable well-being.

Findings:

During a review of the Dietary Supervisor's (DS) Food Card certificate, dated 12/5/2023, the certificate indicated the DS was recognized for successfully completing the food Handler basic course.

During a review of the DS's school transcript, dated Spring 2025, the transcript indicated the DS was enrolled in Introduction of food service work and Food production management.

During an interview on 2/11/2025 at 8:30 a.m. with Dietary [NAME] (DC) 1, DC 1 stated the DS began working as the facility's dietary supervisor in December 2024. DC 1 stated the DS used to work as a cook for

the facility.

During an interview on 2/12/2025 at 1:27 p.m. with the Registered Dietician (RD), the RD stated the facility did not have a DS but the facility had a job posting. The RD stated she was physically at the facility on Tuesdays only and on the other days no one was in charge of the kitchen because there was no DS.

During an interview on 2/13/2025 at 2:08 p.m. with DS, the DS stated she was in school taking classes to become the DS. The DS stated she had been working as the facility's DS while she was in school. The DS stated she over saw the kitchen activities.

During an interview on 2/14/2025 at 11:00 a.m. with the Director of Nursing (DON), the DON stated the DS was interim under the RD's supervision. The DON stated she did not know what education was required to be qualified for the DS position. The DON stated the DS was not qualified to work as a DS because she was still in school. The DON stated the RD was not at the facility everyday and when the RD was not at the facility the DS was in charge of the kitchen and residents' dietary needs.

During a review of the facility's job description titled Director of Food Services, undated, the job description indicated the DS must be a graduate of an accredited course in diuretic training approved by the American Dietetic Association (academy committed to improving the nation's health and advancing the profession of dietetics through research, education and advocacy). The job description indicated the DS must have training in cost control, food management and diet therapy. The job description indicated the DS must be registered as a food service director in this state.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 48 056417 Department of Health & Human Services Printed: 09/08/2025 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 056417 B. Wing 02/14/2025

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

View Heights Conv Hosp 12619 S. Avalon Blvd Los Angeles, CA 90061

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 0803 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Level of Harm - Minimal harm or potential for actual harm 45009

Residents Affected - Many Based on observation, interview and record review, the facility did not ensure dietary staff followed the dietary menus for 146 residents out of 146 sampled residents by failing to:

1. Ensure dietary staff provided a breakfast sandwich with sausage.

2. Ensure the Dietary Supervisor (DS) checked the food before it was provided to residents.

These deficient practices had the potential to impact resident's nutritional status and placed all residents at risk for unintentional weight loss.

Findings:

During an observation on 2/13/2025 at 7:11 a.m. in the kitchen, breakfast sandwich without meat was served to the residents. The breakfast sandwich contained only scrambled eggs.

During an interview on 2/13/2025 at 7:20 a.m. with the DS, the DS stated they were serving a vegetarian (diet with no meat) breakfast sandwich. The DS stated the breakfast sandwich did not come with meat and that made it a vegetarian sandwich.

During a concurrent observation and interview on 2/13/2025 at 7:39 a.m. with Dietary [NAME] (DC) 2, DC 2 stated she was serving residents a sandwich with scrambled eggs for breakfast. DC 2 stated the breakfast sandwich was supposed to have sausage, but she did not have any sausage in the kitchen. DC 2 stated per

the menu all residents were supposed to receive sausage on their sandwich. DC 2 stated she notified the DS about not having sausage and she was serving the sandwiches without sausage. DC 2 stated this had happened before when the kitchen did not have any sausage for the resident meals. DC 2 stated it was important to serve residents a meal that provided nutritional value.

During a concurrent interview and record review on 2/13/2025 at 8:36 a.m. with the DS, the menu dated 2/13/2025 was reviewed. The [NAME] Spreadsheet indicated residents had to receive a breakfast sandwich with sausage meat. The DS stated cooks must follow the menu when cooking for residents. The DS stated

she did not know the breakfast sandwich had to have meat. The DS stated she was supposed to check on

the food that was served to the residents, but she did not. The DS stated when she observed food being plated, she did not notice anything wrong with the food. The DS stated she did not notice the breakfast sandwiches did not have sausage. The DS stated it was important to provide all residents with the correct nutrition to prevent weight loss.

During a review of facility's Recipe titled Mc muffin Sandwich (breakfast sandwich), dated 2024, the recipe indicated breakfast sandwich needed 1 teaspoon of margarine, 1 fried egg, 1/2 ounce slice of cheddar cheese and 1 sausage patty.

During a review of facility's Policy and Procedure (P&P) titled Menu Planning dated 2020, the P&P indicated menus are planned to meet nutritional needs of residents in accordance with national guidelines.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 48 056417 Department of Health & Human Services Printed: 09/08/2025 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 056417 B. Wing 02/14/2025

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

View Heights Conv Hosp 12619 S. Avalon Blvd Los Angeles, CA 90061

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 0803 During a review of facility's Job Description titled Cook, undated, the job description indicated cooks' primary purpose was to prepare food in accordance with current applicable federal, state and local standards, Level of Harm - Minimal harm or guidelines and regulations. The job description indicated cooks must review menus prior to preparation of potential for actual harm food and

Residents Affected - Many During a review of facility's Job Description titled Director of Food Services, undated, the job description indicated the DS would monitor food services to assure all residents' food services needs were met.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 48 056417 Department of Health & Human Services Printed: 09/08/2025 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 056417 B. Wing 02/14/2025

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

View Heights Conv Hosp 12619 S. Avalon Blvd Los Angeles, CA 90061

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 0806 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47286

Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure residents' food preferences were respected, alternates were provided, and food allergy was noted on the diet card (a document that listed a resident's dietary needs, including allergies, preferences, and restrictions) for three of 29 sampled residents (Resident 97, Resident 51, and Resident 81) when:

1. Resident 97 was not provided with an alternative lunch substitute on 2/11/2025, and Resident 97's preference for two quesadillas for lunch and dinner was not documented timely in the medical record.

2. Resident 51's preference for a snack of fresh fruit, was documented timely in the medical record from admission.

3. Resident 81's preference of not having beans was not honored on 2/13/2025 during lunch.

4. Resident 81's shrimp allergy was not documented on the diet card on 2/13/2025.

These deficient practices had the potential to result in Resident 97 and 81's decreased meal intake, and at risk for weight loss and malnutrition. This deficient practice also had the potential to result in Resident 51 not being able to receive their preferred choice of a healthier snack, and lead to a delay in their desired weight loss. This deficient practice had the potential to result in Resident 81's shrimp allergic reaction (body's immune system overreacted to proteins found in shrimp) resulting in possible itching, swelling, hives, or difficulty breathing.

Findings:

During an observation on 2/11/2025 at 12:17 p.m., in the dining room, Resident 97 was observed telling Licensed Vocational Nurse (LVN) 3 she did not want the tofu, and Resident 97 was observed asking LVN 3 for a cheese quesadilla. LVN 3 was observed going to the kitchen.

1. During a review of Resident 97's Admission Record, the Admission Record indicated Resident 97 was admitted to the facility on [DATE REDACTED]. Resident 97's admitting diagnoses included anemia (a condition where the body does not have enough healthy red blood cells), type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and high blood pressure.

During a review of Resident 97's Minimum Data Set (MDS, a resident assessment tool), dated 12/26/2024,

the MDS indicated Resident 97 did not have cognitive impairments (problems with thinking, learning, or memory). The MDS indicated Resident 97 could eat independently and was independent with mobility while both in and out of bed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 48 056417 Department of Health & Human Services Printed: 09/08/2025 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 056417 B. Wing 02/14/2025

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

View Heights Conv Hosp 12619 S. Avalon Blvd Los Angeles, CA 90061

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 0806 During an interview on 2/11/2025 at 10:17 a.m., with Resident 97, Resident 97 stated she did not like the meals she was currently receiving, and stated she preferred to have a cheese quesadilla for lunch and Level of Harm - Minimal harm or dinner. Resident 97 stated staff only offered substitutes of either a peanut butter sandwich, grilled cheese potential for actual harm sandwich, or salad. Resident 97 stated she did not like those options, and stated she requested a cheese quesadilla instead. Resident 97 stated facility staff told her a quesadilla was not an option. Residents Affected - Few

During a concurrent observation and interview on 2/11/2025 at 12:15 p.m., with Resident 97 in the dining room, Resident 97's lunch tray was observed. Resident 97's lunch tray had a plate with tofu, sauteed vegetables, and a scoop of white rice. Resident 97 stated she did not want to eat the tofu, stating it did not look appetizing. Resident 97 stated she preferred to have a quesadilla instead.

During an observation on 2/11/2025 at 12:19 p.m., in the dining room, LVN 3 was observed telling Resident 97 that the kitchen could not provide a quesadilla, and LVN 3 asked Resident 97 if she wanted a peanut butter sandwich, grilled cheese sandwich, or another salad instead. Resident 97 declined these options, and LVN 3 was observed taking Resident 97's plate, and LVN 3 told Resident 97 she would bring her something different from the tofu.

During an observation on 2/11/2025 at 12:21 p.m., in the dining room, LVN 3 was observed placing a new plate onto Resident 97's lunch tray. The new plate had sauteed vegetable and a scoop of rice. There was no quesadilla on the plate as requested by Resident 97.

During an interview on 2/11/2025 at 12:23 p.m., with LVN 3, LVN 3 stated the only other alternatives available to the residents were a peanut butter sandwich, a grilled cheese sandwich, or a salad. LVN 3 stated she requested for a quesadilla from the Director of Staff Development (DSD), but it was not available.

During an interview on 2/11/2025 at 12:24 p.m., with the DSD, the DSD stated she was assisting to pass out trays, but she did not know if quesadillas were available to residents as a substitute. The DSD directed the surveyor to speak with the Dietary Supervisor (DS).

During an interview on 2/11/2025 at 12:25 p.m., with the DS, the DS stated the kitchen had the ingredients needed to make a cheese quesadilla. The DS stated the option to have a cheese quesadilla was not included on the substitute request list, but residents could request one. The DS stated this substitution request would need to be submitted before the lunch trays were served.

During an interview on 2/11/2025 at 12:36 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated CNA staff were responsible for completing and submitting the substitute request form to the kitchen if a resident requested something different from what was being served. CNA 1 stated the option for a quesadilla was not provided to residents.

During a concurrent observation and interview on 2/12/2025 at 12:18 p.m., in the dining room, Resident 97's lunch tray was observed. Resident 97 had a sandwich with two un-melted slices of cheese, and an assortment of raw vegetables, on a plate. Resident 97 had a side of soup and a bowl of fruit in syrup. Resident 97 stated she requested a quesadilla and did not receive one.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 48 056417 Department of Health & Human Services Printed: 09/08/2025 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 056417 B. Wing 02/14/2025

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

View Heights Conv Hosp 12619 S. Avalon Blvd Los Angeles, CA 90061

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 0806 During a concurrent observation and interview on 2/12/2025 at 2:10 p.m., with the Registered Dietician (RD), Resident 97's lunch tray, and replacement tray provided by LVN 3, was observed. The RD stated it was not Level of Harm - Minimal harm or appropriate to remove the tofu and not provide an alternative item. The RD stated she was supposed to be potential for actual harm notified whenever kitchen staff were making substitutions to a resident's tray to ensure that the substitute provided was of similar or equal nutritional value. The RD stated LVN 3's actions was not appropriate, and Residents Affected - Few placed Resident 97 at risk of not having her nutrient needs met by the meal. The RD stated this placed Resident 97 at risk for malnourishment and loss of muscle mass. The RD also stated if the kitchen had the ingredients necessary to make an item requested by the resident, it should be prepared and provided to the resident. The RD stated that providing residents with meals of their choice was their right and promoted the resident's autonomy.

During a review of Resident 97's diet order on 2/12/2024 at 4:11 p.m., dated 11/14/2024, the diet order did not reflect Resident 97's preference to have cheese quesadillas for lunch and dinner.

During an interview on 2/13/2024 at 10:04 a.m., with Resident 97, Resident 97 stated she spoke with staff on 2/12/2025 about her preference to have two quesadillas for lunch and dinner.

During a review of Resident 97's diet order on 2/13/2025 at 10:15 a.m., the diet order did not reflect Resident 97's preference to have cheese quesadillas for lunch and dinner.

During a concurrent interview and record review on 2/13/2025 at 2:50 p.m., with the RD, Resident 97's diet order was reviewed. The RD stated resident food preferences would be indicated in the resident's diet order, and stated Resident 97's diet order did not reflect the preference for cheese quesadillas. The RD stated she spoke with Resident 97 on 2/12/2025 about her preference cheese quesadillas for lunch and dinner. The RD stated she would change the order after the interview.

During a concurrent interview and record review, on 2/14/2025 at 9:24 a.m., with the Director of Nursing (DON), Resident 97's diet order was reviewed. The DON stated Resident 97's diet order was revised on 2/13/2025 at 3:57 p.m. to reflect the preference to have cheese quesadillas for lunch and dinner. The DON stated a resident's dietary preferences were to be reviewed and updated in the electronic medical record (EMR) as needed and stated that if the dietary staff were aware on 2/12/2025 of Resident 97's request for cheese quesadillas for lunch and dinner, the diet order should have been updated on 2/12/2025. The DON stated prompt update of the EMR to reflect those preferences would ensure the kitchen staff could prepare a meal to accommodate the preference. The DON stated that when preferences were not accommodated or respected, and a resident was not eating, it could lead to weight loss and malnutrition. The DON also stated that the trays provided should meet the resident's nutritional needs and stated kitchen staff should be communicating with the RD if substitutes were requested.

During a review of the facility document titled Alternative Menu Request - Only One Alternative, undated, the facility document indicated the alternative options available to the facility residents. The document indicated

the option of a salad, peanut butter sandwich, or grilled cheese sandwich. The document did not provide nursing staff the option to indicate any other food items the resident might request, including a quesadilla.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 48 056417 Department of Health & Human Services Printed: 09/08/2025 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 056417 B. Wing 02/14/2025

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

View Heights Conv Hosp 12619 S. Avalon Blvd Los Angeles, CA 90061

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 0806 During a review of the facility policy and procedure (P&P) titled Daily Food Menu Alternative - Food Substitutions for Residents who Refuse the Meal, dated 1/2024, the P&P indicated residents were to be Level of Harm - Minimal harm or provided a suitable nourishing alternate meal after the planned, served meal was refused. The P&P indicated potential for actual harm residents were to be offered food according to their stated preferences and indicated updating of the resident's preferences was to be done as the residents' needs changed. Residents Affected - Few 2. During a review of Resident 51's Admission Record, the Admission Record indicated Resident 51 was admitted on [DATE REDACTED]. Resident 51's admitting diagnoses included obesity (the state or condition of being very fat or overweight).

During a review of Resident 51's MDS, dated [DATE REDACTED], the MDS indicated Resident 51 did not have cognitive impairments. The MDS indicated Resident 51 reported it was very important to have snacks available between meals while in the facility and indicated Resident 51 could eat independently. The MDS indicated Resident 51 was independent with all mobility while in and out of bed.

During an interview on 2/11/2025 at 10:55 a.m., with Resident 51, Resident 51 stated she received oatmeal cream cookies as a snack between meals but preferred to have a healthier option. Resident 51 stated she preferred to have fresh fruit. Resident 51 stated she did not recall anyone talking to her about her food preferences about what she would like to eat.

During an interview on 2/12/2025 at 2:10 p.m., with the RD, the RD stated inquiries about food preferences, diet changes, and or requests were not routinely documented in the resident's progress notes, dietary profiles, or nutritional assessments by nursing staff. The RD stated she and the DS were responsible for conducting reviews of residents' food preferences, and stated the facility did not currently have an official DS, therefore the task of assessing food preferences was currently her responsibility. The RD stated she was onsite at the facility one day a week. The RD stated there was no system in place for her to assure that she spoke with and assessed all residents who had questions or concerns related to their food preferences or diet.

During an interview on 2/13/2025 at 2:42 p.m., with the RD, the RD stated she was unaware of Resident 51's stated preference to have fresh fruit as a snack between meals.

During a review of Resident 51's physician orders, progress notes, dietary profile, and nutritional assessments, on 2/14/2025 at 8:26 a.m., there were no records indicating Resident 51's preference for fresh fruit as a snack.

During an interview on 2/14/2025 at 9:24 a.m., with the DON, Resident 51's physician orders, progress notes, dietary profile, and nutritional assessments since admission, were reviewed. The DON stated that based on the documentation, there was no way for staff to know of Resident 51's preference for fresh fruit as

a snack between meals. The DON stated fresh fruit was a nutritious option and was available in the kitchen.

The DON stated it was Resident 51's right to be offered and provided with their preferred snack choice.

During a review of the facility P&P titled Daily Food Menu Alternative - Food Substitutions for Residents who Refuse the Meal, dated 1/2024, the P&P indicated residents were to be offered food according to their stated preferences and indicated updating of the resident's preferences was to be done as the residents' needs changed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 48 056417 Department of Health & Human Services Printed: 09/08/2025 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 056417 B. Wing 02/14/2025

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

View Heights Conv Hosp 12619 S. Avalon Blvd Los Angeles, CA 90061

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 0806 3. During a review of Resident 81's Admission Record, the Admission Record indicated Resident 81 was originally admitted on [DATE REDACTED] and readmitted on [DATE REDACTED]. Resident 81's admitting diagnoses included Level of Harm - Minimal harm or schizoaffective disorder (a mental illness that could affect thoughts, mood, and behavior). The Admission potential for actual harm Record indicated Resident 81 was allergic to shrimp and had a public guardian (responsible for the care of individuals who were no longer able to make decisions or care for themselves). Residents Affected - Few

During a review of Resident 81's MDS, dated [DATE REDACTED], the MDS section F indicated Resident 81 reported it was very important to have snacks available between meals while in the facility.

During a review of Resident 81's MDS, dated [DATE REDACTED], the MDS section C indicated Resident 81 did not have cognitive impairments, and the MDS section GG indicated Resident 81 could eat independently. The MDS section GG indicated Resident 81 was independent with all mobility while in and out of bed.

During a review of Resident 81's physician orders report, dated from 2/1/2025 -2/14/2025, the report indicated Resident 81did not want beans and needed protein replacement for beans with all meals.

During an observation and interview on 2/13/2025 at 12:42 p.m. with Resident 81, in facility's dining room, black beans were observed on Resident 81's lunch plate. Resident 81's preference of not wanting beans was not on the diet card. Resident 81 used fork to push away the black beans on his lunch plate and stated he did not like beans.

During an observation and interview on 2/13/2025 at 12:42 p.m. with Resident 81, in facility's dining room, shrimp allergy was not on Resident 81's diet card. Resident 81 stated he was allergic to shrimp, and the diet card used to have the shrimp allergy on but not anymore.

During a review of facility's menu, dated 2/13/2025, the menu indicated black beans was served for lunch.

During an interview on 2/13/2025 at 3:19 p.m. with the RD, the RD stated the diet card should have resident's food allergy because it was important to not give food that resident was allergic to. The RD stated resident might receive the food that they were allergy to and have allergic reaction if there was no allergy information on the diet card. The RD stated the DS needed to check resident's diet card every day. The RD stated it was not acceptable to have the diet card without the allergy information if resident had food allergy.

During a concurrent picture review and interview on 2/13/2025 at 3:19 p.m. with the DS, Resident 81's diet card picture, dated 2/13/2025 at 1:51 p.m., was reviewed. The picture indicated the diet card did not have Resident 81's preference of not wanting beans. The DS stated Resident 81's diet card did not indicate shrimp allergy. The DS stated resident's food allergy needed to be on the diet card because facility did not want to serve the food resident were allergic to. The DS stated resident might have allergic reaction, such as itchy throat, hives, and closed throat which was life threatening. The DS stated she was responsible to check

the diet card against resident's diet list and allergy. The DS stated it was possible to wash off resident's allergy information which was written on the diet cards when sanitizing. The DS stated staff should not put beans on the plate because they need to follow the diet order. The DS stated resident might decrease oral intake and potentially result in weight lost when preference was not respected.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 48 056417 Department of Health & Human Services Printed: 09/08/2025 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 056417 B. Wing 02/14/2025

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

View Heights Conv Hosp 12619 S. Avalon Blvd Los Angeles, CA 90061

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 0806 During a review of the facility P&P titled Food Allergies, dated 12/2024, the P&P indicated Steps are taken to prevent resident exposure to the allergen(s)(a substance that can cause an allergic reaction) and Severe Level of Harm - Minimal harm or food allergies are noted on the face of the chart and communicated in writing directly to the dietitian and the potential for actual harm director of food and nutrition services.

Residents Affected - Few During a review of the facility P&P titled Tray Card System Policy, dated 12/2024, the P&P indicated Each meal tray at breakfast, lunch and dinner will have a tray card which designates the resident's name, diet, food dislikes, food allergies, and portion (serving) size.

49900

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 48 056417 Department of Health & Human Services Printed: 09/08/2025 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 056417 B. Wing 02/14/2025

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

View Heights Conv Hosp 12619 S. Avalon Blvd Los Angeles, CA 90061

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 0809 Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to Level of Harm - Minimal harm or eat at non-traditional times or outside of scheduled meal times. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47679 Residents Affected - Few Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled Nourishment Policy for two of two residents (Resident 56 and Resident 81) by failing to:

a. Provide Resident 56 snacks when requested.

b. Provide Resident 81 snacks.

This deficient practice violated Resident 56 and 81's rights to eat as they wanted to.

Findings:

1. During a review of Resident 56's Admission Record (Face Sheet), the Face Sheet indicated Resident 56 was initially admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses that included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), alcohol dependence (a chronic disease where the individual craves drinks with alcohol and unable to control their drinking), and nicotine dependence (a compulsive need for nicotine, the additive chemical in tobacco products).

During a review of Resident 56's Minimum Data Set ([MDS], a resident assessment tool), dated 11/13/2024,

the MDS indicated Resident 56's cognition (process of thinking) was intact. The MDS indicated Resident 56 was independent with eating, toileting, bathing, and dressing.

During a review of Resident 56's Orders, dated 2/1/2025 through 2/28/2025, the Orders indicated Resident 56 was on a regular diet (a meal plan that allows the individual to eat a variety of foods without restrictions).

During an interview on 2/11/2025 at 8:03 a.m., with Resident 56, Resident 56 stated when he asked the nurses for a snack, they would not give him a snack.

During an interview on 2/13/2025 at 10:15 a.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated the scheduled snack times were 10 a.m., 2 p.m., and 8 p.m. CNA 2 stated all the residents received a snack at 2 p.m., but only specific residents on the Nourishments list would receive specific snacks at 10 a.m. and 8 p.m. CNA 2 stated when a resident requests additional snacks, the licensed nurse would have to consult with the Registered Dietician (RD) whether or not the resident could receive additional snacks.

During an interview on 2/13/2025 at 10:19 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated if a resident requested for additional snacks, the resident would have to be weighed and the RD would be consulted to see if the resident was allowed an additional snack.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 48 056417 Department of Health & Human Services Printed: 09/08/2025 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 056417 B. Wing 02/14/2025

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

View Heights Conv Hosp 12619 S. Avalon Blvd Los Angeles, CA 90061

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 0809 During a concurrent interview and record review at 2/13/2025 at 2:59 p.m., with the RD, the facility's Nourishment and Time, dated 2/13/2025, was reviewed. The RD stated residents were allowed up to three Level of Harm - Minimal harm or snacks per day. The RD stated every resident received a snack at 2 p.m., however, only specific residents potential for actual harm were allowed a snack at 10 a.m. and 8 p.m. based on her clinical assessment if the resident required additional calories. The RD stated Resident 56 was not on the Nourishment list to receive snacks at 10 a.m. Residents Affected - Few and 8 p.m. The RD stated if a resident requested additional snacks, the licensed nurse would inform her, and

the additional snacks would not be provided to the resident until she (RD) assessed the resident at the facility.

49900

2. During a review of Resident 81's Face Sheet, the Face Sheet indicated Resident 81 was originally admitted on [DATE REDACTED] and readmitted on [DATE REDACTED]. Resident 81's admitting diagnoses included schizoaffective disorder (a mental illness that could affect thoughts, mood, and behavior). The Face Sheet indicated Resident 81 had a public guardian (responsible for the care of individuals who were no longer able to make decisions or care for themselves).

During a review of Resident 81's MDS, dated [DATE REDACTED], the MDS indicated Resident 81 reported it was very important to have snacks available between meals while in the facility.

During a review of Resident 81's MDS, dated [DATE REDACTED], the MDS indicated Resident 81 did not have cognitive impairments. The MDS indicated Resident 81 could eat independently, and was independent with all mobility while in and out of bed.

During a review of Resident 81's physician orders report, dated from 2/1/2025 -2/14/2025, the report indicated Resident 81 was on a low fat diet (an eating plan that limited fat to 30 percent (%) or less of your daily calories).

During an interview on 2/11/2025 at 10:21 a.m. with Resident 81, in Resident 81's room, Resident 81 stated

he was not provided snacks when he asked staff. Resident 81 stated the nurse (unidentified) told him that staff could not provide snacks if it was not on paper. Resident 81 stated he felt inadequate and not as important as other residents.

During an interview on 2/13/2025 at 4:17 p.m., with the Director of Nursing (DON), the DON stated residents should be provided additional snacks when requested. The DON stated if a resident was hungry and wanted

a snack, outside of the normal snack and mealtimes, the resident should be provided a snack, and the licensed nurse should inform the RD so the RD could assess the resident's needs and preferences. The DON stated snacks should not be withheld from the resident while they wait for the RD to assess them. The DON stated if a resident was hungry, it was the responsibility of the facility to feed them. The DON stated withholding additional snacks from a resident put the resident at risk of hunger and weight loss.

During a review of the facility's policy and procedure (P&P) titled, Nourishment Policy, dated 12/2024, the P&P indicated, Snacks must be provided to residents who want to eat at non-traditional times or outside of scheduled snack times. The P&P indicated facility shall provide nourishments up to three times per day.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 48 056417 Department of Health & Human Services Printed: 09/08/2025 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 056417 B. Wing 02/14/2025

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

View Heights Conv Hosp 12619 S. Avalon Blvd Los Angeles, CA 90061

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

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

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

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45009

Residents Affected - Many Based on observation, interview, and record review the facility failed to ensure safe and sanitary food storage practices in the kitchen that affected 146 residents out of 146 sampled residents when:

1. The walk -in refrigerator contained lettuce with no in date (the date when the food was placed in the refrigerator), no use by date (date the food item must be consumed by) and cheese with no use by date.

2. The dry storage room did not have a thermometer to monitor room temperature.

3. The walk-in refrigerator had three bags of expired spinach.

These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illnesses in all residents who received food from the kitchen.

Findings:

During the initial kitchen tour observation on [DATE REDACTED] at 8:31 a.m., the walk-in refrigerator was observed with

a bag of cheese without a use by date, bags of spinach that were expired and lettuce that was not labeled and undated.

During the initial kitchen tour observation on [DATE REDACTED] at 8:44 a.m., in the dry storage room, the storage room did not have a thermometer.

During an interview on [DATE REDACTED] at 8:51 a.m. with Dietary cook (DC) 1, in the dry storage room, DC 1 stated there must be a thermometer in the dry storage room, but she could not find it. DC 1 stated when the dietary staff added new food items into storage room, they misplaced it. DC 1 stated it was important to have a thermometer in the dry storage room to monitor temperatures daily and without a thermometer there was no way of knowing if temperature was within the required temperature range.

During an interview on [DATE REDACTED] at 8:59 a.m. with DC 1, DC 1 stated the spinach bags were expired and should not be in the refrigerator. DC 1 stated the cheese should have a use by date and the lettuce should be labeled with the correct dates. DC 1 stated all food items placed in the refrigerator should have an in date and a use by date to inform all staff if food item was still good to be used. DC 1 stated it was important to date all food items to inform staff if food item was safe to consume.

During an interview on [DATE REDACTED] at 7:49 a.m. with the Dietary Supervisor (DS), the DS stated all food that goes into a refrigerator must be dated with an in date and a use by date to prevent residents from getting sick. The DS stated if food items were not labeled, they could potentially serve old food to residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 48 056417 Department of Health & Human Services Printed: 09/08/2025 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 056417 B. Wing 02/14/2025

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

View Heights Conv Hosp 12619 S. Avalon Blvd Los Angeles, CA 90061

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 facility's Policy and Procedure (P&P) titled Dry Storage Areas, dated ,d+[DATE REDACTED], the P&P indicated storeroom temperature should be 50 degrees to 70 degrees Fahrenheit ([F], scale for temperature). Level of Harm - Minimal harm or The P&P indicated a thermometer must be present in the storeroom and storeroom must be monitored on a potential for actual harm regular basis.

Residents Affected - Many During a review of facility's P&P titled Dietary Refrigerated Storage, dated ,d+[DATE REDACTED], the P&P indicated food items should be arranged so that older items will be used first, by dating food items would facilitate this practice. The P&P indicated all food items are to be stored in the refrigerator for the correct amount of time.

The P&P indicated all leftover food would be covered, labeled and dated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 48 056417 Department of Health & Human Services Printed: 09/08/2025 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 056417 B. Wing 02/14/2025

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

View Heights Conv Hosp 12619 S. Avalon Blvd Los Angeles, CA 90061

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 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47679 potential for actual harm Based on interview and record review, the facility failed to ensure one of three sampled residents' (Resident Residents Affected - Few 21) conservator (a person who has been appointed by the court to make decisions for another person who is deemed incompetent) understood the Arbitration Agreement (an agreement between the facility and the resident where they would resolve any disputes through a neutral person rather than going to court) in a language Conservator 1 understood.

This deficient practice resulted in Conservator 1 not understanding what entering a binding Arbitration Agreement meant.

Findings:

During a review of Resident 21's Admission Record (Face Sheet), the Face Sheet indicated Resident 21 was admitted to the facility on [DATE REDACTED] with diagnoses that included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), alcohol dependence (a chronic disease where the individual craves drinks with alcohol and unable to control their drinking), and nicotine dependence (a compulsive need for nicotine, the additive chemical in tobacco products). The Face Sheet indicated Conservator 1 was Resident 21's private conservator and responsible party.

During a review of Resident 21's Minimum Data Set ([MDS], a resident assessment tool), dated 1/31/2025,

the MDS indicated Resident 21's cognition (process of thinking) was intact. The MDS indicated Resident 21 was independent with eating, toileting, bathing, and dressing.

During a review of Resident 21's Resident-Facility Arbitration Agreement, dated 7/15/2024, the Resident-Facility Arbitration Agreement indicated Conservator 1 signed and entered the binding agreement

on behalf of Resident 21. The Resident-Facility Arbitration Agreement was in English.

During an interview on 2/12/2025 at 4:48 p.m., with Conservator 1, Conservator 1 stated her primary language was Spanish and paperwork from the facility was given to her in English. Conservator 1 stated she spoke very little English and was unable to explain what arbitration was.

During an interview on 2/13/2025 at 8:30 a.m., with the Admissions Coordinator (AC), the AC stated the facility only offered the Resident-Facility Arbitration Agreement in English. The AC stated if a resident or their conservator's primary language of Spanish, a translator would explain the Resident-Facility Arbitration Agreement to them in Spanish. The AC stated the facility should have the Resident-Facility Arbitration Agreement in different languages to ensure the resident and their conservator could read and understand the contract before deciding to enter the binding Arbitration Agreement. The AC stated although the contract was translated in Spanish to Conservator 1, if Conservator 1 wanted to refer back to the contract, which was in English, Conservator 1 would not be able to have a full understanding of the Arbitration Agreement.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 48 056417 Department of Health & Human Services Printed: 09/08/2025 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 056417 B. Wing 02/14/2025

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

View Heights Conv Hosp 12619 S. Avalon Blvd Los Angeles, CA 90061

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 0848 Provide a neutral and fair arbitration process and agree to arbitrator and venue.

Level of Harm - Minimal harm or 47679 potential for actual harm Based on interview and record review, the facility failed to include the selection of a venue that was Residents Affected - Many convenient to both parties in the Arbitration Agreement (an agreement between the facility and the resident where they would resolve any disputes through a neutral person rather than going to court).

This deficient practice had the potential to cause bias in venue selection process for residents who enter into

a binding arbitration agreement and want to resolve a dispute.

Findings:

During a concurrent interview and record review on 2/13/1015 at 12:57 p.m., with the Administrator (ADM),

the facility's Resident-Facility Arbitration Agreement, undated, was reviewed. The ADM stated the facility had updated the Resident-Facility Arbitration Agreement to indicate a section for the selection of a venue that was convenient to both parties, however, the Resident-Facility Arbitration Agreement currently utilized was not the updated version. The ADM stated the facility's administration was responsible for providing the updated Resident-Facility Arbitration Agreement to the Admissions Coordinator (AC), who would review the contract with the resident and their conservator (a person who has been appointed by the court to make decisions for another person who is deemed incompetent). The ADM stated the residents and their conservators who signed on their behalf were given the wrong version of the Resident-Facility Arbitration Agreement.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 48 056417 Department of Health & Human Services Printed: 09/08/2025 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 056417 B. Wing 02/14/2025

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

View Heights Conv Hosp 12619 S. Avalon Blvd Los Angeles, CA 90061

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 49900 potential for actual harm Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) Residents Affected - Many titled Water Temperature Policy For Facility Laundry and Preventative Maintenance Policy by failing to:

1. Monitor the washer water temperature on 2/14/2025.

2. Clean the dyer lint trap (a mesh filter located inside a dryer that caught lint and fabric fibers from clothes

during the drying cycle) on 2/14/2025.

This deficient practice had the potential to increase the risk of infection which could increase the morbidity (the amount of disease in a population) and mortality (the state of being subject to death) among 146 residents residing in the facility.

Findings:

1. During a concurrent observation and interview on 2/14/2025 at 9:21 a.m. with the Maintenance Supervisor (MS), in the facility's laundry room, there were no monitors on the washer indicating the water temperature.

The MS stated the water temperature needed to be between 125-165 degrees Fahrenheit ( F, a measurement of temperature). The MS stated the facility was unable to read the water temperature of the washers because the monitor was broken for the past few days. The MS stated staff checked the water temperature by feeling how hot the outside of the washer viewing glasses was, and the chlorine (a disinfectant that killed germs in water) in the washing solution also disinfected the linen. The MS stated they ordered the new monitors for the washer and waiting for the delivery. The MS stated staff were not certain if

the linen was getting cleaned or disinfected properly when they did not know the water temperature.

2. During a concurrent observation and interview on 2/14/2025 at 9:40 a.m. with the MS, in the facility's laundry room, the dryer lint trap had lint. The MS stated staff were supposed to remove the dryer lint twice a shift, starting with the morning shift at 5:30 a.m.

During a concurrent interview and record review on 2/14/2025 at 9:42 a.m. with the MS, in the facility's laundry room, the dryer lint removal log, dated 2/2025, was reviewed. The log indicated no documentation on

the dryer lint removal on 2/14/2025 at 7 a.m. nor at 9 a.m. The log further indicated staff were to remove lint from the lint trap after every 3rd load or 2 hours of operation per manufacturer requirements. The MS stated staff were supposed to clean the dryer lint trap at 9 a.m. but it was not done. The MS stated the risk was fire, and the dryer temperature would drop and affect the linen sanitizing process. The MS stated if the linen was not dry enough, staff would double dry the linen to make sure they were dry.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 48 056417 Department of Health & Human Services Printed: 09/08/2025 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 056417 B. Wing 02/14/2025

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

View Heights Conv Hosp 12619 S. Avalon Blvd Los Angeles, CA 90061

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

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

F 0880 During an interview on 2/14/2025 at 9:59 a.m. with the Infection Preventionist Nurse (IPN), the IPN stated the dryer might not kill all the bacteria and viruses in the linen if the dryer lint trap was not clean. The IPN stated Level of Harm - Minimal harm or staff were unsure if the linen were cleaned properly nor if the bacteria was killed when the washer water potential for actual harm temperature was not monitored. The IPN stated the linen might not be clean and cause infection among residents. The IPN stated residents might experience signs and symptoms of sickness and cold with cough. Residents Affected - Many

During a review of the facility's Policy and Procedure (P&P) titled, Water Temperature Policy For Facility Laundry, dated on 12/2014, the P&P indicated Water temperatures shall be at least maintained at a minimum reading of 160 F for a minimum of 25 minutes for hot water washing. The temperature will be monitored at the beginning, middle and end of shift.

During a review of the facility's P&P titled, Preventative Maintenance Policy, dated on 12/2014, the P&P indicated The dryer lint trap or filter will be cleaned after every two dryer loads. Careful records should be kept making sure all cleanings have been recorded noting the time of each cleaning.

During a review of the facility's P&P titled, Standard Infection Precaution, dated on 12/2014, the P&P indicated Handle, transport, and process used linen soiled with blood, body fluids, secretions, excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and avoids transfer of microorganisms to other residents and environments.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 48 056417 Department of Health & Human Services Printed: 09/08/2025 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 056417 B. Wing 02/14/2025

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

View Heights Conv Hosp 12619 S. Avalon Blvd Los Angeles, CA 90061

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 0920 Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. Level of Harm - Minimal harm or potential for actual harm 45009

Residents Affected - Many Based on observation, interview, and record review, the facility failed to accommodate residents in the dining room during mealtimes by not ensuring:

1. The dining room offered enough space for all residents to sit down at the same time for mealtime.

2. Residents were sent to not their rooms to wait until a seat became available.

3. Residents were asked to form a line to wait for a seat to become available.

This deficient practice had the potential to affect Resident's self-esteem and self-worth.

Findings:

During an observation on 2/11/2025 at 12:10 p.m., in the dining room, the dining room was observed having 40 chairs.

During an observation on 2/11/2025 at 12:22 p.m., in the dining room, residents were observed forming a line at the entrance of the dining room. Residents were in line waiting for a seat to become available.

During an observation on 2/12/2025 at 12:07 p.m., in the dining room, an identified resident walked into the dining room, looked around the room for a place to sit and remained standing in the middle of the dining room because he could not find an empty seat. Certified Nursing Assistant (CNA) 3 asked the resident to go stand by the door until there was an available seat for the resident to use.

During an observation on 2/13/2025 at 1216 p.m., in the dining room, an unidentified resident was observed entering the dining room but could not find an available seat. CNA 3 told the resident to go to back to their room and he (CNA 3) would call the resident when there was an available chair. The resident stood standing

in the middle of the dining room looking around at all seated residents. CNA 3 told resident again to go back to her room and the resident left the dining room.

During an interview on 2/13/2025 at 12:18 p.m. with CNA 3, in the dining room, CNA 3 stated the dining room did not have enough space for all residents to sit down and eat together. CNA 3 stated residents must wait until there was an available chair for them. CNA 3 stated residents must wait against the wall while the other residents seated were eating. CNA 3 stated the dining room did not have enough chairs for all the residents and that was the reason why residents had to wait to eat.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 48 056417 Department of Health & Human Services Printed: 09/08/2025 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 056417 B. Wing 02/14/2025

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

View Heights Conv Hosp 12619 S. Avalon Blvd Los Angeles, CA 90061

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 0920 During an interview on 2/14/2025 at 10:35 a.m. with the Director of Nursing (DON), the DON stated the north side of the facility housed 50 residents and the dining room had 40 chairs to accommodate residents during Level of Harm - Minimal harm or mealtimes. The DON stated staff sent residents back to their rooms to wait for a seat because the facility's potential for actual harm dining room could not accommodate all residents. The DON stated it was an acceptable practice to send residents back to their rooms or have them wait in line because they could not accommodate all the Residents Affected - Many residents. The DON stated this practice would make residents feel bad because they were sent away and had to wait to eat.

During a review of the facility's Policy and Procedure (P&P) titled Dining Room Service dated 12/2024, the P&P indicated meals would be distributed promptly to maintain adequate temperature and appearance. The P&P indicated all individuals should be encouraged to sit in a dining room chair.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 48 056417