West Pico Terrace Healthcare & Wellness Centre Lp

F-F656

Findings:

During record review, the Admission Record indicated Resident 10 was originally admitted to the facility on [DATE REDACTED] and was readmitted on [DATE REDACTED] with diagnoses including cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue), Parkinson's disease (a chronic brain disorder that causes movement problems, and can also affect mental health, sleep, and pain), Type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and muscle wasting and atrophy (characterized by a significant shortening of the muscle fibers and a loss of overall muscle mass).

During record review, the Minimum Data Set (MDS - resident assessment tool) dated 2/6/2025, indicated Resident 10's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS indicated Resident 10 required maximal assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).

During the initial tour of the facility and observation of Resident 10 on 2/7/2025 at 6:23 p.m., Resident 10 was observed in bed, lying on a bed with a bilateral (both) siderails up. Resident 10 was observed asking staff for assistance on opening food container.

During record review of Resident 10's Order Summary Report as of 2/9/2025, indicated there was no physician order for the use of bilateral bed siderails.

During record review of Resident 10's Care Plan (CP) as of 2/9/2025, indicated there are no CP developed for the use of bilateral siderails.

During an interview with Director of Nursing (DON) on 2/9/2025 at 6:14 p.m., DON stated, the bed side rails are used as an enabler. DON stated there should be a physician's order and CP for the use of bed siderails as it limits resident movements and can be a restraint.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 34 055119 Department of Health & Human Services Printed: 09/09/2025 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 055119 B. Wing 02/09/2025

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

West Pico Terrace Healthcare & Wellness Centre LP 6070 W. Pico Boulevard Los Angeles, CA 90035

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 0604 During record review of the facility's policy and procedures (P&P) titled, Bed Rails, reviewed on 6/20/2024,

the P&P indicated, A bed rail is an assistive device and must be used in accordance with the following Level of Harm - Minimal harm or regulations: . are classified as a physical restrain when bed rails are used to limit a Resident's freedom of potential for actual harm movement . A detailed order by a healthcare provider is required before any restrains can be utilized.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 34 055119 Department of Health & Human Services Printed: 09/09/2025 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 055119 B. Wing 02/09/2025

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

West Pico Terrace Healthcare & Wellness Centre LP 6070 W. Pico Boulevard Los Angeles, CA 90035

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 0625 Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44253

Residents Affected - Few Based on interview, and record review, the facility failed to provide a bed hold notification (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization ) in writing at the time of transfer to the hospital for one of three sampled residents (Resident 38).

This deficient practice denied Resident 38 or the Responsible Party (RP) of being informed of resident's right to have the facility hold and reserve his bed while absent from the facility.

Findings:

During record review of Resident 38's Admission Record (Face Sheet) indicated Resident 38 was initially admitted to the facility on [DATE REDACTED], and was readmitted on [DATE REDACTED], with diagnoses including metabolic encephalopathy (brain damage that causes severe confusion and forgetfulness), bladder cancer and chronic kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood).

During record review of Resident 38's Bed Hold Agreement form, dated 12/6/24 indicated the form had three sections, the first was To be Completed upon Admission or Return to Facility, the second was Notification of Bed Hold option upon transfer/therapeutic leave and the third was 24 Hour Notification of Bed Hold Decision.

A review of the Bed Hold Agreement form also indicated Under the section To be Completed upon Admission, indicated Resident 38's responsible party (RP) was informed that the resident or RP had the right to request the facility hold the bed for seven days should the resident be transferred to an acute hospital and

the resident or RP must notify the facility within 24 hours of transfer/leave if the resident wished to have the bed held. This section of the form was signed by the RP on 12/6/24. A further review of Bed Hold Agreement form indicated the second and third sections were not filled out and were unsigned.

During record review, Resident 38's Minimum Data Set (MDS- a resident assessment tool) dated 12/30/24, indicated the resident's cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was intact. The MDS indicated Resident 38 required substantial assistance (helper does less than half to more than half the effort) from staff for toileting hygiene, showering/bathing and lower body dressing.

During record review, Resident 38's Physician Order, dated 2/5/25, indicated to transfer Resident 38 to the Emergency Department (ED) via 911 for further evaluation of hypotension (low blood pressure).

During record review, Resident 38's Progress Note dated 2/5/25 indicated at 9:10 AM the resident had a blood pressure of 80/60 (normal 120/80) and the nurse practitioner ordered the resident transferred to General Acute Care Hospital (GACH) 1. The progress note also indicated Resident 38 was transferred via 911 (a telephone number used to reach emergency medical, fire, and police services) to GACH 2.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 34 055119 Department of Health & Human Services Printed: 09/09/2025 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 055119 B. Wing 02/09/2025

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

West Pico Terrace Healthcare & Wellness Centre LP 6070 W. Pico Boulevard Los Angeles, CA 90035

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 0625 During record review of Resident 38's Skilled Nursing Home/Nursing Home (SNF/NF) to Hospital Transfer Form, dated 2/5/25, indicated the resident was transferred to GACH 2. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 2/9/25 at 12:38 PM with Registered Nurse Supervisor (RNS) 1, Resident 38's electronic health record was reviewed. RNS 1 stated Resident 38 was transferred to Residents Affected - Few a general acute care hospital on 2/5/25 for low blood pressure and high heart rate. RNS 1 stated the facility did not notify Resident 38 or the responsible party of the resident's right to a bed hold during or after the transfer. RNS 1 stated a bed hold notification is required to be offered upon transfer in order to guarantee the resident has a bed to return to upon readmission.

During an interview with on 2/09/25 at 5:59 PM, the Director of Nursing (DON) stated, the policy is to inform

the resident of their right to a bed hold upon transfer.

During record review, the facility's policy and procedures (P&P) titled, Bed Hold, revised 7/2017, indicated,

the facility notifies the resident and/or representative, in writing, of the bed hold option, any time the resident is transferred to an acute care hospital or request therapeutic leave.

During record review, the facility's P&P titled, Discharge and Transfer of Residents, revised 2/2018, indicated, the purpose of the policy was to ensure that discharge planning is complete and appropriate and that necessary information is communicated to the continuing care provider. The P&P also indicated upon transfer to the acute hospital the resident/resident representative will be given an opportunity to execute a bed hold.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 34 055119 Department of Health & Human Services Printed: 09/09/2025 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 055119 B. Wing 02/09/2025

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

West Pico Terrace Healthcare & Wellness Centre LP 6070 W. Pico Boulevard Los Angeles, CA 90035

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 0637 Assess the resident when there is a significant change in condition

Level of Harm - Minimal harm or 45528 potential for actual harm Based on interview and record review, the facility failed to complete a change of condition (COC -a sudden Residents Affected - Few deviation from person/patient's baseline in physical, cognitive, behavioral or function) in accordance with the facility's policy and procedures (P&P) titled Change of Condition Notification reviewed 6/20/2024 for one out of six residents (Resident 23)

This deficiency practice had the potential to result in the delay of care for Resident 23.

Findings:

During record review, Resident 23's Admission Record indicated the facility admitted Resident 23 on 7/3/2023 with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough), personal history of transient ischemic attack (TIA - a temporary blockage of blood flow to the brain) and cerebral vascular accident (CVA- Stroke) without residuals, and hypertension (HTN - elevated blood pressure).

During record review of Resident 23's Minimum Data Set (MDS - resident assessment tool) dated 1/10/2025, indicated Resident 23 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 23 required extensive staff assistance with activities of daily living (ADL -tasks of everyday life).

During a concurrent interview and record review, on 2/9/2025, at 8:45 a.m., with Registered Nurse Supervisor 1 (RNS 1), Resident 23's electronic chart was reviewed. RNS 1 stated there was no documented evidence that a COC was completed for Resident 23 on 9/15/2025. RNS 1 stated A COC is done to see if there is any new or continuous change in the resident's condition and since residents 23 continued to have aggressiveness, combativeness and continuously refused to allow staff to collect the urine sample ordered by the physician, a COC documentation should have been done. RNS 1 stated lack of completion of the coc leads to lack of recommendations needed on how to deal with the changes.

During an interview, on 2/9/2025, at 4:04 p.m., with the Director of Nursing (DON), the DON stated that a COC is done to so residents can be monitored, and the Interdisciplinary team can be involved in providing resident with the care needed and if not done no one will know or monitor what is going on.

During record review of the facility's P&P, titled, Change of Condition Notification reviewed 6/20/2024, indicated, Purpose: To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner .

A. A need to alter treatment significantly (e.g. based on labs/x-ray results, a need to discontinue an existing form of treatment due to change of condition).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 34 055119 Department of Health & Human Services Printed: 09/09/2025 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 055119 B. Wing 02/09/2025

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

West Pico Terrace Healthcare & Wellness Centre LP 6070 W. Pico Boulevard Los Angeles, CA 90035

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 0655 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Level of Harm - Minimal harm or potential for actual harm 45528

Residents Affected - Few Based on interview and record review, the facility failed to immediately develop and implement a baseline care plan according to their Policy and Procedures (P&P) in accordance with the facility's policy and procedures (P&P) titled Comprehensive Person-Centered Care planning revised 11/2018 for one of four sampled residents (Resident 6), by failing to:

1. Address the inclusion of activity programs that are tailored to Resident 6's interests and to Resident 6's cognitive, physical/functional and social abilities to stimulate and facilitate Resident 6's social engagement.

2. Outline a personalized treatment strategy for Resident 6's hearing loss within 48 hours of admission.

These deficient practices had the potential to negatively affect the delivery of necessary care and services for Resident 6.

Findings:

During record review, Resident 6's Admission Record indicated the facility admitted Resident 6 on 11/23/2024 with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough), generalized weakness (a feeling of weakness in most parts of the body), and adult failure to thrive (a noticeable decline in health).

During record review, the physician order dated 11/23/2024, indicated audiology (a medical study of hearing and balance, and treatment of related disorders) consult with follow up treatment as indicated for Resident 6.

During record review, the history and physical (H&P -a physician's examination of the patient) dated 11/25/2024 at 10:46 a.m., indicated .past medical history . hard of hearing for Resident 6.

During record review, Resident 6's Minimum Data Set (MDS - resident assessment tool) dated 11/30/2024, indicated Resident 6 had mild cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 6 required extensive staff assistance with activities of daily living (ADL -tasks of everyday life). The MDS further indicated Resident 6 had moderate difficulty with hearing and severely impaired vision.

During an interview, on 2/8/2025, at 2:21 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 6 was hard of hearing, and that facility staff have to go very close to her ear and speak very loud for Resident 6 to hear.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 34 055119 Department of Health & Human Services Printed: 09/09/2025 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 055119 B. Wing 02/09/2025

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

West Pico Terrace Healthcare & Wellness Centre LP 6070 W. Pico Boulevard Los Angeles, CA 90035

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 0655 During a concurrent interview and record review, on 2/9/2025, at 10:04 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 6's electronic chart was reviewed. RNS 1 stated a care plan for activities is for Level of Harm - Minimal harm or staff to know what interventions to take to achieve the goal for the resident to participate in the activities that potential for actual harm the resident prefers. RNS 1 stated Resident 6 did not have documented evidence of an activity care plan in her chart. RNS 1 further stated that lack of an activity care plan for Resident 6, facility staff will not know her Residents Affected - Few activity preference.

During a concurrent interview and record review, on 2/9/2025, at 1:47 p.m., with Activities Director (AD), Resident 6's electronic chart was reviewed. AD stated, a care plan provides residents with the services that

the residents needs and for other facility staff to know what activities needs the resident has before even meeting the resident. AD stated Resident 6 did not have a documented activity care plan and that and that Resident 6 needed to have one. AD further stated, if the resident does not have a care plan for activities, the team members will nots know how to handle the resident in regard to their activities which may lead to the residents feeling sad and neglected.

During an interview, on 2/9/2025, at 4:14 p.m., with Director of Nursing (DON), DON stated base line care plans are supposed to be initiated within 48 hours of admission which includes a personalized activity care plan for the team to know how to take care of the resident. DON stated potential adverse outcome of not having an activity care plan is that the staff may not know the type of activities the Resident prefers and may lead resident to be sad and depressed (sadness, hopeless and loss of interest).

During record review, the facility's policy and procedures, titled, Comprehensive Person-Centered Care Planning revised 11/2018, indicated, Purpose: To ensure that a comprehensive person-centered care plan is developed for each resident .

1. Baseline Care plan .

b. The baseline care plan will be developed and implemented, using necessary combination of problem specific care plans, within 48 hours of the resident admission .

c. The baseline care plan must reflect the resident's stated goals and objectives and include interventions that address his or her needs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 34 055119 Department of Health & Human Services Printed: 09/09/2025 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 055119 B. Wing 02/09/2025

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

West Pico Terrace Healthcare & Wellness Centre LP 6070 W. Pico Boulevard Los Angeles, CA 90035

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 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43454

Residents Affected - Few Based on interview and record review, the facility failed to implement a comprehensive care plan (CP) that met the care/services based on the resident's individual assessed needs for one of six sampled residents (Resident 10), by failing to ensure that a comprehensive CP was developed with the use of Resident 10's bilateral (both) bed siderails, when Resident 10 was hospitalized on [DATE REDACTED], 7/22/2024, and 12/27/2024.

This deficient practice had the potential to result in a negative impact on residents' health and safety, as well as the quality of care and services received.

Findings:

A review of the Admission Record indicated Resident 10 was originally admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnosis including cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue), Parkinson's disease (a chronic brain disorder that causes movement problems, and can also affect mental health, sleep, and pain), Type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and muscle wasting and atrophy (characterized by a significant shortening of the muscle fibers and a loss of overall muscle mass).

A review of Resident 10's Minimum Data Set (MDS - resident assessment tool) dated 2/6/2025, indicated Resident 10's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS indicated Resident 10 required maximal assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).

During the initial tour of the facility and observation of Resident 10 on 2/7/2025 at 6:23 p.m., observed resident 10 in bed, lying on a bed with a bilateral siderails up. Observed Resident 10 asking staff for assistance on opening food container.

A review of Resident 10's CP as of 2/9/2025, indicated there are no CP developed for the use of bilateral siderails. Furthermore, there are no CP when Resident 10 was hospitalized due to altered mental status on 6/29/2024, chest pain on 7/22/2024 and productive cough and generalized weakness on 12/27/2024.

During an interview with Registered Nurse (RN) 1 on 2/8/2025 at 3:39 p.m., RN 1 reviewed Resident 10's chart and stated and confirmed, there are no CP developed for the use of bilateral bed siderails. RN 1 further stated, there are also no CP when Resident 10 had a change of condition (COC) and was hospitalized on [DATE REDACTED], 7/22/2024 and 12/27/2024. RN 1 stated, a CP should be developed when residents had COC, so that they can update the plan of care and manage the problems.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 34 055119 Department of Health & Human Services Printed: 09/09/2025 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 055119 B. Wing 02/09/2025

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

West Pico Terrace Healthcare & Wellness Centre LP 6070 W. Pico Boulevard Los Angeles, CA 90035

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 an interview with Director of Nursing (DON), on 2/9/2025 at 6:14 p.m., the DON stated, the bed side rails are used as an enabler. DON stated there should be a physician's order and CP for the use of bed Level of Harm - Minimal harm or siderails as it limits resident movements and can be a restraint. DON further stated, there should also be CP potential for actual harm for each hospitalization and COC so that all staff are on the same page on managing resident's plan of care.

Residents Affected - Few A review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, reviewed on 6/20/2024, the P&P indicated, Is it the policy of this facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being . The comprehensive care plan will also be reviewed and revised at the following times: onset of new problems; change of condition.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 34 055119 Department of Health & Human Services Printed: 09/09/2025 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 055119 B. Wing 02/09/2025

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

West Pico Terrace Healthcare & Wellness Centre LP 6070 W. Pico Boulevard Los Angeles, CA 90035

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 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Level of Harm - Minimal harm or potential for actual harm 44253

Residents Affected - Few Based on observation, interview, and record review, the facility failed to revise the enteral feeding care plan to meet the individual needs for one of two sampled residents (Resident 22).

This deficient practice had the potential to prevent Resident 22 from receiving care to address specific needs, which could lead to a decline in her nutrition.

Findings:

A review of Resident 22's Admission Record indicated the facility admitted Resident 22 on 10/9/24 with diagnoses including cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain) dysphagia (difficulty swallowing) and heart failure (a disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling).

A review of Resident 22's Minimum Data Set [MDS - a resident assessment tool] dated 1/8/25 indicated the resident had severely impaired cognition (never/rarely made decisions) and was totally dependent upon staff for eating, oral hygiene, toileting hygiene, lower body dressing and personal hygiene. The MDS also indicated Resident 22 had a feeding tube.

A review of Resident 22's physician order dated 1/16/25, indicated to give Jevity 1.5 at 65 milliliters (ml, unit of measurement) per hour (hr) via gastrostomy tube (GT - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) for dysphagia (difficulty swallowing).

During an observation on 2/7/25 at 6:08 PM at Resident 22's bedside, Resident 22 was observed lying in bed awake with Jevity 1.5 calorie formula bottle infusing at 65 ml/hr.

During a record review on 2/8/25 at 12:22 PM, Resident 22's Requires tube feeding care plan, initiated 10/9/24, was reviewed. The care plan indicated Resident 22's current enteral feeding order was for Jevity 1.5 to infuse at 40 ml/hr. The care plan indicated the goal was for the resident to maintain adequate nutritional and hydration status. A further review of the care plan indicated the care plan did not include the resident's current enteral feeding order.

During a concurrent interview and record review on 2/8/25 at 1:08 PM, Resident 22's physician orders and care plans were reviewed with Registered Nurse Supervisor (RN) 1. RN 1 stated Resident 22's current enteral feeding order was Jevity 1.5 at 65 ml/hr. RN 1 stated Resident 22's enteral feeding care plan was not updated with the current physician order. RN 1 stated should have been updated in order for all staff to know

the current interventions in place. RN 1 further stated not updating the care plan could lead to the Resident not receiving the proper care.

During an interview on 2/9/25 at 5:57 PM, the Director of Nursing (DON) stated the staff update the care plan when the changes in the resident's care, medication or enteral feeding occurs. The DON confirmed the findings and stated the care plan should be updated so the resident receives appropriate care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 34 055119 Department of Health & Human Services Printed: 09/09/2025 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 055119 B. Wing 02/09/2025

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

West Pico Terrace Healthcare & Wellness Centre LP 6070 W. Pico Boulevard Los Angeles, CA 90035

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 0657 A review of the facility's policy and procedure (P&P ) titled, Comprehensive Person-Centered Care Planning, revised 11/2018, the P&P indicated, the comprehensive care plan will the comprehensive care plan will be Level of Harm - Minimal harm or periodically reviewed and revised by the interdisciplinary team (IDT, - a group of healthcare professionals potential for actual harm from different disciplines [nurses, social worker, therapist, physician, etc.] that provide care for the residents)

after each assessment which means after each MDS assessments as required, accept discharge Residents Affected - Few assessments. In addition, the comprehensive care plan will also be reviewed and revised at the following times:

i. onset of new problems;

ii. change of condition;

iii. in preparation for discharge;

iv. to address changes in behavior and care;

v. other times as appropriate or necessary.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 34 055119 Department of Health & Human Services Printed: 09/09/2025 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 055119 B. Wing 02/09/2025

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

West Pico Terrace Healthcare & Wellness Centre LP 6070 W. Pico Boulevard Los Angeles, CA 90035

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 45528 potential for actual harm Based on interview and record review, the facility failed to notify the physician when they were unable to Residents Affected - Few collect urine sample for urinalysis, culture and sensitivity (UA [a test to check if the urine has an infection, kidney problem, diabetes or liver disease] and C&S [test to find germs & the type of antibiotics they respond to]) for one of three sampled residents (Resident 23) per physician's orders.

This deficient had the potential to result in the delay of the appropriate instructions needed from the physician to prevent infection and hospitalization .

Findings:

A review of Resident 23's Admission Record indicated the facility admitted Resident 23 on 7/3/2023 with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough), personal history of transient ischemic attack (TIA - a temporary blockage of blood flow to the brain), and cerebral vascular accident (CVA- Stroke) without residuals, and hypertension (HTN - elevated blood pressure).

A review of Resident 23's Minimum Data Set (MDS - a resident assessment tool) dated 1/10/2025, indicated Resident 23 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 23 required extensive staff assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).

A review of Resident 23's change of condition (COC -a sudden deviation from person/patient's baseline in physical, cognitive, behavioral or function) effective 9/12/2024 at 2:48 p.m., indicated Licensed Vocational Nurse (LVN) documented that on 9/12/2024 Certified Nursing Assistant (CNA) informed LVN that Resident 23 was aggressive/combative during ADL care. The COC indicated that on 9/12/2024 at 2:40 p.m., the LVN relayed Resident 23's condition to the physician who gave an order to collect a urine sample for UA, C&S via straight catheter.

A review of the physician order dated 9/15/2024 at 11:04 a.m., indicated transfer to General Acute Care Hospital (GACH) for further evaluation and treatment possible Urinary Tract Infection (UTI-an infection of the urinary tract, which includes the kidneys, ureters, bladder, and urethra).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 34 055119 Department of Health & Human Services Printed: 09/09/2025 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 055119 B. Wing 02/09/2025

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

West Pico Terrace Healthcare & Wellness Centre LP 6070 W. Pico Boulevard Los Angeles, CA 90035

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 concurrent interview and record review on 2/9/2025, at 8:45 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 23's electronic chart was reviewed. RNS 1 stated that the facility's process for an order for Level of Harm - Minimal harm or a routine (a standard or regular way of doing something) urine sample collection, was that the facility needs potential for actual harm to attempt collection of the urine sample three times and if not successful, then they need to notify the doctor. RNS 1 stated the COC on 9/12/2024 indicated that Resident 23 was aggressive and combative while Residents Affected - Few performing ADL care. RNS 1 stated aggressiveness and combativeness maybe a sign (something a doctor, or other person, notices) and symptoms (is what a person/patient feels) of a UTI and if the urine sample was not collected, there would not be any lab results to treat the resident. RNS 1 further stated if the UTI was left untreated, it may lead to sepsis (a life threatening blood infection) and possibly prolonged hospitalization . RNS 1 stated there was no documented evidence that Resident 23's physician was notified when the facility failed to collect the urine sample after three attempts.

During an interview with the Director of Nursing (DON), on 2/9/2025, at 4:04 p.m., the DON stated that the urine sample was supposed to be collected as soon as possible when the order was received. The DON stated if the urine sample was not able to be collected after trying three consecutive shifts, then the physician needs to be notified. The DON stated a UA, C&S is a urine sample that is ordered when a resident is suspected of having a UTI. The DON further stated if a UTI was left untreated, it could lead to sepsis.

A review of the facility's policy and procedures (P&P), titled, Refusal of Treatment revised 1/1/2012, the P&P indicated, Procedure .

IV. The attending Physician will be notified of refusal of treatment in a time frame determined by the resident's condition and potential serious consequences of the refusal.

VI. When the residents refusal brings about a significant change in the resident's condition, a reassessment is made, and new information is incorporated into the residents care plan.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 34 055119 Department of Health & Human Services Printed: 09/09/2025 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 055119 B. Wing 02/09/2025

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

West Pico Terrace Healthcare & Wellness Centre LP 6070 W. Pico Boulevard Los Angeles, CA 90035

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 0685 Assist a resident in gaining access to vision and hearing services.

Level of Harm - Minimal harm or 45528 potential for actual harm Based on interview and record review, the facility failed to provide outside services as required by physician Residents Affected - Few orders in accordance with the facility's policy and procedures (P&P) titled Referral to Outside Services revised on 12/1/2013, by failing to refer one of four sampled residents (Resident 6) to an audiologist (a healthcare professional that specializes in evaluating and treating hearing problems, like hearing loss).

This deficient practice had the potential to negatively affect the delivery of necessary care and services for Resident 6.

Findings:

A review of Resident 6's Admission Record indicated the facility admitted Resident 6 on 11/23/2024 with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough), generalized weakness (a feeling of weakness in most parts of the body), and adult failure to thrive (a noticeable decline in health).

A review of Resident 6's physician order dated 11/23/2024, indicated audiology (a medical study of hearing and balance, and treatment of related disorders) consult with follow up treatment as indicated.

A review of Resident 6's History and Physical (H&P -a physician's examination of the patient) dated 11/25/2024 at 10:46 a.m., indicated .past medical history . hard of hearing.

A review of Resident 6's Minimum Data Set (MDS - a resident assessment tool) dated 11/30/2024, indicated Resident 6 had mild cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 6 required extensive staff assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The same MDS further indicated Resident 6 had moderate difficulty with hearing and severely impaired vision.

During an interview with Certified Nursing Assistant (CNA) 1, on 2/8/2025, at 2:21 p.m., CNA 1 stated Resident 6 was hard of hearing. CNA 1 further stated that the facility staff had to go very close to Resident 6's ear and speak very loud for Resident 6 to hear.

During a concurrent interview and record review, on 2/9/2025, at 10:18 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 6's electronic chart was reviewed. RNS 1 stated Resident 6 had a referral to audiology on 11/23/2024 however, there was no documented evidence in Resident 6's chart that the resident was seen by audiology. RNS 1 further stated that social services was responsible for making the appointment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 34 055119 Department of Health & Human Services Printed: 09/09/2025 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 055119 B. Wing 02/09/2025

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

West Pico Terrace Healthcare & Wellness Centre LP 6070 W. Pico Boulevard Los Angeles, CA 90035

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 0685 During a concurrent interview and record review, on 2/9/2025, at 11:09 a.m., with the Social Services Director Interim (SSDI), Resident 6's electronic chart was reviewed. SSDI stated, facility process was that Level of Harm - Minimal harm or when there was a physician's order for referral to ancillary (extra or supporting services that are added onto potential for actual harm the main service) services, the referral to the requested specialty was sent the day of admission or the day that the order was received. SSDI stated Resident 6 had an order for audiology consult on 11/23/2024 Residents Affected - Few however, there was no documented evidence that a referral to audiology was made. SSDI stated Resident has hard of hearing and has a hard time hearing the staff which may lead her to get frustrated. The SSDI confirmed and stated that it had been 13 weeks since the order was given.

During an interview with the Director of Nursing (DON), on 2/9/2025, at 4:14 p.m., the DON stated that the facility's process for an audiology or ancillary order, was that the social services was notified, the social services then notifies the audiologist of the order right away. The SSDI then puts the resident on the audiology or ancillary list and the resident will be seen when the audiologist comes into the facility. The DON further stated if the audiologist was not notified of the referral order, there will be a delay in the care and the evaluation of the resident. The DON further stated delaying the evaluation of Resident 6 would ultimately affect the overall communication with the resident, and the resident may end up feeling depressed (sadness, hopeless).

A review of the facility's policy and procedures (P&P), titled, Referral to Outside Services revised 12/1/2013,

the P&P indicated, To provide residents with outside services as required by physician orders or the care plan .The Director of Social Services coordinates the referral of residents to outside agencies/programs to fulfill resident needs for services not offered by the Facility .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 34 055119 Department of Health & Human Services Printed: 09/09/2025 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 055119 B. Wing 02/09/2025

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

West Pico Terrace Healthcare & Wellness Centre LP 6070 W. Pico Boulevard Los Angeles, CA 90035

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** 43454

Residents Affected - Few Based on interview, observation, and record review, the facility failed to maintain a safe, functional and comfortable environment for one of six sampled residents (Resident 4), by failing to ensure the exit pathway was clear of geriatric (relating to old people, especially with regard to their healthcare) recliner chairs (geri-chair - large, padded chairs with wheeled bases, and are designed to assist seniors with limited mobility) and clutter.

This failure had the potential to place Resident 4 at risk of fire hazards injury and accidents.

Findings:

A review of the Admission Record indicated Resident 4 was originally admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnosis including pneumonia (lung infection that inflames air sacs with fluid or pus), acute respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), hemiplegia and hemiparesis (total paralysis of the arm, leg, and trunk on the same side of

the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting left dominant side.

A review of Resident 4's Minimum Data Set (MDS - resident assessment tool) dated 12/20/2024, indicated Resident 4's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS indicated Resident 4 required maximal to total dependent from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).

During a concurrent observation and interview with Resident 4 on 2/7/2025 at 7:13 p.m., Resident 4 stated, her exit door pathway is obstructed with geri-chairs and it's blocking her view to the outside. Resident 4 stated, she asked the staff to have it move because she's scared that if they need to evacuate her due to fire, it will be blocking the way, and she also feels uncomfortable because she doesn't like how it's blocking her view. Observed six geri-chairs outside her door which completely blocked the exit pathway.

During an interview with Maintenance Supervisor (MS) on 2/8/2025 at 11:40 a.m., MS stated, they put the geri-chair outside Resident 4's room because of the recent rains. MS stated, he was aware of Resident 4's complaint about the geri-chair and how it is blocking the pathway but he has not moved the equipment away. MS stated the exit pathway is not a storage area and it should be clear of any equipment.

During an interview with Director of Nursing (DON) on 2/9/2025 at 6:01 p.m., DON stated, the exit pathway should be clear in case of fire, earthquake and any emergency. DON stated, resident might feel unsafe when

the exit pathway is blocked and obstructed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 34 055119 Department of Health & Human Services Printed: 09/09/2025 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 055119 B. Wing 02/09/2025

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

West Pico Terrace Healthcare & Wellness Centre LP 6070 W. Pico Boulevard Los Angeles, CA 90035

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 A review of the facility's policy and procedure (P&P) titled, Resident Rooms and Environment, reviewed on 6/20/2024, the P&P indicated, The facility provides residents with a safe, clean, environment, and homelike Level of Harm - Minimal harm or environment. Facility Staff will provide residents with a pleasant environment and person-centered care that potential for actual harm emphasizes the residents' comfort, independence, and personal needs and preferences.

Residents Affected - Few A review of the facility's P&P titled, Resident Safety, reviewed on 6/20/2024, the P&P indicated, Purpose: To provide a safe and hazard free environment . Any facility staff member who identifies an unsafe situation, practice or environment risk factor should immediately notify their supervisor or charge nurse.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 34 055119 Department of Health & Human Services Printed: 09/09/2025 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 055119 B. Wing 02/09/2025

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

West Pico Terrace Healthcare & Wellness Centre LP 6070 W. Pico Boulevard Los Angeles, CA 90035

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 0693 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Level of Harm - Minimal harm or potential for actual harm 44253

Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents' (Resident 22) enteral feeding (refers to any method of feeding that uses the gastrointestinal (stomach/intestines) tract to deliver nutrition and calories) bottle was changed after 24 hours.

This deficient practice had the potential for the residents to develop tube feeding associated complications such as infection.

Findings:

During record review, Resident 22's Admission Record indicated the facility admitted Resident 22 on 10/9/24 with diagnoses including cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain) dysphagia (difficulty swallowing), and heart failure (a disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling).

During record review, Resident 22's Requires Tube Feeding care plan, initiated 10/9/24, indicated the resident had dysphagia. The care plan indicated a goal was for the resident to not have side effects or complication related to tube feeding. The interventions indicated staff were to monitor for signs or symptoms of infection, assist/supervise/cue the resident with tube feeding and water flushes and to see physician orders for current feeding orders.

During record review, Resident 22's Minimum Data Set (MDS - a resident assessment tool), dated 1/8/25, indicated the resident had severely impaired cognition (never/rarely made decisions) and was totally dependent upon staff for eating, oral hygiene, toileting hygiene, lower body dressing and personal hygiene.

The MDS also indicated Resident 22 had a feeding tube.

During record review, Resident 22's physician order dated 2/4/25, indicated to give Jevity 1.5 at 65 milliliters (ml-unit of measurement) per hour (ml/hr) via gastrostomy tube (GT - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) for dysphagia (difficulty swallowing) via pump for 20 hours for 20 hours to provide 1300 milliliters (ml) per day, and to start the infusion at 12 PM and turn off at 8 AM.

During an observation on 2/7/25 at 6:08 PM at Resident 22's bedside, Resident 22 was observed lying in bed awake with Jevity 1.5 calorie formula bottle (1500cc) infusing at 65 ml/hr. Resident 22's tube feeding was dated 2/6/25 at 9 AM.

During a concurrent observation and interview on 2/7/25 at 6:11 PM, Resident 22's tube feeding was observed with Licensed Vocational Nurse (LVN) 1. LVN 1 stated Resident 22's tube feeding was dated 2/6/25 at 9 AM. LVN stated the maximum hang time (amount of time formula can stay at room temperature

before it's used) for an enteral feeding is 24 hours. LVN 1 stated leaving the tube feeding hanging for more than 24 hours cold lead to infection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 34 055119 Department of Health & Human Services Printed: 09/09/2025 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 055119 B. Wing 02/09/2025

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

West Pico Terrace Healthcare & Wellness Centre LP 6070 W. Pico Boulevard Los Angeles, CA 90035

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 0693 During an interview on 2/9/25 at 5:55 PM, the Director of Nursing (DON) stated staff change entering feeding bottles every day for infection control. The DON further stated we follow manufacturer's instructions when Level of Harm - Minimal harm or administering tube feeding. potential for actual harm

During record review, the facility's policy and procedures titled, Enteral Feeding - Closed, revised 1/1/2012, Residents Affected - Few indicated ,as part of the procedure staff should:

VII. Connect container and tubing. Formula may 'hang' for 24-48 hours, depending on manufacturer guidelines.

VIII. Label the formula container and tubing with date and time hung.

XI. Change feeding formula and tubing every 24-48 hours or as required by manufacturer guidelines.

According to the National Library of Medicine liquid ready to hang (RTH) formulas offer increased hang times of up to 48 hours. However, most closed containers are discarded after 24 hours due to current manufacturer recommendations to change enteral feeding sets every 24 hours and to spike each closed container only once https://pmc.ncbi.nlm.nih. gov/articles/PMC7519612/#:~:text=Sterile%20liquid%20RTH%20formulas%20offer, each%20closed%20container%20only%20once.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 34 055119 Department of Health & Human Services Printed: 09/09/2025 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 055119 B. Wing 02/09/2025

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

West Pico Terrace Healthcare & Wellness Centre LP 6070 W. Pico Boulevard Los Angeles, CA 90035

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 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43454 potential for actual harm Based on observation, interview, and record review, the facility failed to provide necessary respiratory care Residents Affected - Few services for one of three sampled residents (Resident 30), by failing to ensure the nasal cannula (NC -a connector attached to oxygen) tubing and humidifier (a device used to make supplemental oxygen moist) for oxygen (O2) therapy was changed per facility's policy.

This deficient practice had the potential to cause complications associated with oxygen therapy.

Findings:

During record review, the Admission Record indicated Resident 30 was originally admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnosis including acute bronchospasm (a sudden narrowing of the airways [bronchi] in the lungs, caused by the contraction of muscles lining the airways), pulmonary embolism (a blood clot gets stuck in an artery in the lung, blocking blood flow to part of the lung), Type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure).

During record review, the Minimum Data Set (MDS - resident assessment tool) dated 12/13/2024, indicated Resident 30's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS indicated Resident 30 required set-up assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).

During record review, Resident 30's Order Summary Report dated 11/7/2022, the physician ordered, Change O2 NC tubing and humidifier every Monday for oxygen use, label and date properly.

During a concurrent observation and interview with Resident 30 on 2/7/2025 at 6:03 p.m., Resident 30 stated that he was having some shortness of breath (SOB) and on oxygen therapy. Resident 30 was observed with

an oxygen concentrator machine connected to a NC tubing and humidifier at bedside. Resident 30's NC tubing and humidifier bottle did not have a written label with date attached.

During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 3 on 2/7/2024 at 6:10 p. m., LVN 3 observed Resident 30's NC tubing and humidifier bottle and stated and confirmed, there are no written date labeled on the NC tubing and humidifier. LVN 3 further stated, he did not know when the NC was last changed.

During an interview with Registered Nurse (RN) 1 on 2/8/2025 at 4:04 p.m., RN 1 stated, the NC tubing and humidifier is to be changed every seven days, and it must be labeled with the date so they know when it was last changed.

During an interview with Director of Nursing (DON) on 2/9/2025 at 6:04 p.m., DON stated, the NC tubing and humidifier is replaced once a week and as needed for infection control. DON stated, if the humidifier bottle and NC tubing does not have any label, it must be changed to a new set-up and dated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 34 055119 Department of Health & Human Services Printed: 09/09/2025 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 055119 B. Wing 02/09/2025

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

West Pico Terrace Healthcare & Wellness Centre LP 6070 W. Pico Boulevard Los Angeles, CA 90035

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 0695 During record review, the facility's policy and procedures (P&P) titled, Oxygen Therapy, reviewed on 6/20/2024, the P&P indicated, Oxygen is administered under safe and sanitary conditions to meet resident Level of Harm - Minimal harm or needs . The humidifier and tubing should be changed no more than seven days and labeled with the date of potential for actual harm change.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 34 055119 Department of Health & Human Services Printed: 09/09/2025 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 055119 B. Wing 02/09/2025

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

West Pico Terrace Healthcare & Wellness Centre LP 6070 W. Pico Boulevard Los Angeles, CA 90035

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** 43454

Residents Affected - Few Based on observation, interview and record review, the facility failed to:

1. Ensure to label an open date of one of five sampled residents (Resident 19)'s ipratropium-albuterol inhalation solution (used to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness) inhalation solution that can expire once opened with an open date according to manufacturer guidelines.

2. Ensure Resident 30's medications were not left unattended at the bedside.

These deficient practices had the potential to compromise the therapeutic effectiveness of the stored medications and cause unintended accident concerning medication use.

Findings:

1. A review of the Admission Record indicated Resident 19 was originally admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and muscle weakness (weakening, shrinking, and loss of muscle).

A review of the Minimum Data Set (MDS - resident assessment tool) dated 12/12/2024, indicated Resident 19's cognitive (relating to mental action or process of acquiring knowledge and understanding) skills for daily decisions was moderately impaired.

A review of Resident 19's Order Summary Report dated 12/9/2023 indicated, the physician ordered, ipratropium-Albuterol solution 0.5-2.5 milligram (mg)/3 millimeter (ml) - 1 vial inhale orally every 6 hours as needed for SOB (shortness of breath).

During a concurrent observation and interview with Licensed Vocational Nurse (LVN 2) on 2/8/2025 at 11:49 a.m., Resident 19's ipratropium-albuterol medication was observed in Medication Cart 1 with an opened foil pouch while the unit-dose vials were visible; however, there were no labels of date to indicate when the medication was first opened. LVN 2 stated, the medication should be labeled when it was first opened.

A review of The Ritedose Corporation (manufacturer) guidelines for Ipratropium Bromide and Albuterol Sulfate Inhalation Solution, indicated, Once removed from the foil pouch, the individual vials should be used within two weeks.

A review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, reviewed on 6/20/2024, indicated, The nurse shall place a date opened sticker on the medication and enter the date opened . The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or regulations/guidelines require different dating.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 34 055119 Department of Health & Human Services Printed: 09/09/2025 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 055119 B. Wing 02/09/2025

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

West Pico Terrace Healthcare & Wellness Centre LP 6070 W. Pico Boulevard Los Angeles, CA 90035

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 2. A review of the Admission Record indicated Resident 30 was originally admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including acute bronchospasm (a sudden narrowing of the airways Level of Harm - Minimal harm or [bronchi] in the lungs, caused by the contraction of muscles lining the airways), pulmonary embolism (a blood potential for actual harm clot gets stuck in an artery in the lung, blocking blood flow to part of the lung), DM, and chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure). Residents Affected - Few

A review of the MDS dated [DATE REDACTED], indicated Resident 30's cognitive skills for daily decisions was intact. The MDS indicated Resident 30 required set-up assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).

A review of Resident 30's Order Summary Report as of 2/8/2025 indicated, there was no physician's order that Resident 30 may self-administer own medications.

During a concurrent observation and interview with Resident 30 on 2/7/2025 at 6:03 p.m., a medication cup full of medications was observed at Resident 30's bedside table. Resident 30 stated, the medications were protonix (used to treat heartburn and certain other conditions caused by too much acid in the stomach), fish oil supplements (protect the heart, ease inflammation, improve mental health, and lengthen life) vitamins and medications for his bowels.

During an interview with Licensed Vocational Nurse (LVN 3) on 2/7/2025 at 6:10 p.m., LVN 3 confirmed Resident 30's medications was left at bedside and stated, it is not acceptable to leave medications at bedside. LVN 3 further stated Resident 30 sometimes refuses medications, but it is not acceptable to leave medications for residents to take them whenever they want to.

During an interview with Director of Nursing (DON) on 2/9/2025 at 6:06 p.m., the DON stated, medications should not be left at bedside as other residents may take the medications and may cause accidents and interactions with other medications. The DON further stated, if residents refuse medications, they need to reoffer and document. The DON also stated, the manufacturer guidelines must be followed and the inhalation solution must be labeled when it was first opened so they know when the medication needs to be discarded.

A review of the facility's P&P titled, Medication - Administration, reviewed on 6/20/2024, the P&P indicated, Medications may be administered one hour before or after the scheduled medication administration time . Medications must be given to the resident by the Licensed Nurse preparing the medication . If a resident is refusing to take medication, time of refusal must be documented in the MAR (Medication Administration Record) stating the reason for the refusal. The Licensed Nurse will attempt to give the medications, make more than one attempts, and if the resident continues to refuse, the refused medications will be destroyed. Licensed Nurse will notify Medical Doctor (MD) and document in the medical record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 34 055119 Department of Health & Human Services Printed: 09/09/2025 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 055119 B. Wing 02/09/2025

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

West Pico Terrace Healthcare & Wellness Centre LP 6070 W. Pico Boulevard Los Angeles, CA 90035

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** 43454 Residents Affected - Few Based on observation, interview and record review, the facility failed to properly store one of five sampled residents (Resident 43)'s levalbuterol (used to prevent or relieve the wheezing, shortness of breath, coughing, and chest tightness caused by lung disease) inhalation solution medication that expires once opened according to manufacturer guidelines.

This deficient practice had the potential to compromise the therapeutic effectiveness of the stored medications given to the residents because of inappropriate storage of medications.

Findings:

A review of the Admission Record indicated Resident 43 was admitted to the facility on [DATE REDACTED] with diagnoses including acute respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and acute kidney failure (a condition in which

the kidneys suddenly can't filter waste from the blood).

A review of the Minimum Data Set (MDS - resident assessment tool) dated 12/16/2024, indicated Resident 43's cognitive (relating to mental action or process of acquiring knowledge and understanding) skills for daily decisions was mild impaired. The MDS indicated Resident 43 required moderate assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).

A review of Resident 43's Order Summary Report, dated 12/11/2024, indicated, the physician ordered levalbuterol inhalation nebulization solution 1.25 milligram /3 millimeter (mg/ml - unit of measurement) - 1 vial inhale orally via nebulizer (a device for producing a fine spray of liquid, used for example for inhaling a medicinal drug) four times a day.

During a concurrent observation and interview with Licensed Vocational Nurse (LVN 2) on 2/8/2025 at 11:49 a.m., Resident 43's levalbuterol inhalation solution medications was observed in Medication Cart 1 with the opened foil pouch while the medication box was labeled 1/11/2025. LVN 2 stated, the date labeled was when

the medication was first opened.

During an interview with Director of Nursing (DON) on 2/9/2025 at 6:25 p.m., the DON stated, the manufacturer guidelines must be followed, if the medications were being used after the date and time given by manufacturer guidelines, the medications might not be effective.

A review of The Ritedose Corporation (manufacturer) guidelines Levalbuterol Inhalation Solution, indicated, Once the foil pouch is opened, the vials should be used within two weeks. Once removed from the foil pouch,

the individual vials should be used within one week.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 34 055119 Department of Health & Human Services Printed: 09/09/2025 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 055119 B. Wing 02/09/2025

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

West Pico Terrace Healthcare & Wellness Centre LP 6070 W. Pico Boulevard Los Angeles, CA 90035

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 A review of the facility's policy and procedure (P&P) titled, Medication - Administration, reviewed on 6/20/2024, indicated, Medications may be administered one hour before or after the scheduled medication Level of Harm - Minimal harm or administration time . Medications must be given to the resident by the Licensed Nurse preparing the potential for actual harm medication . If a resident is refusing to take medication, time of refusal must be documented in the MAR (Medication Administration Record) stating the reason for the refusal. The Licensed Nurse will attempt to Residents Affected - Few give the medications, make more than one attempts, and if the resident continues to refuse, the refused medications will be destroyed. Licensed Nurse will notify Medical Doctor (MD) and document in the medical record.

A review of the facility's P&P titled, Medication Storage in the Facility, reviewed on 6/20/2024, indicated, The nurse shall place a date opened sticker on the medication and enter the date opened . The expiration date of

the vial or container will be 30 days unless the manufacturer recommends another date or regulations/guidelines require different dating.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 34 055119 Department of Health & Human Services Printed: 09/09/2025 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 055119 B. Wing 02/09/2025

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

West Pico Terrace Healthcare & Wellness Centre LP 6070 W. Pico Boulevard Los Angeles, CA 90035

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 44253

Residents Affected - Some Based on observation, interview and record review, the facility failed to ensure boxed food items were not stored directly on the floor.

This deficient practice had a potential to cause food contamination, which placed the residents of the facility at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages).

Findings:

During a concurrent interview and observation in the dry storage on 2/5/25 at 5:32 PM with [NAME] 1 (CK1),

the following food items were observed stacked directly on the floor:

a. One box of Thickened dairy drink

b. One box of thickened lemon-flavored water

c. 25- pound bag of sugar

CK1 stated these food items in boxes were delivered earlier in the day and were not placed on the racks. CK1 stated the boxes should be stored at least 6 inches off the floor to prevent contamination and not to spread infection to the residents.

During an interview on 2/8/25 at 4:02 PM, the Dietary Supervisor (DS1) stated boxes are to be stored 6 inches off the floor for infection control.

During an interview on 2/9/25 at 5:59 PM, the Director of Nursing (DON) stated food in the kitchen is to be stored in sanitary manner.

A review of the facility provided storage guidelines, under Section A- Sanitary Conditions in Storage of Food, indicated shelving should be mounted at least 6 inches from the floor, preferably on castors for ease of cleaning and 18 inches from the ceiling and foods should be stored off the floor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 34 055119 Department of Health & Human Services Printed: 09/09/2025 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 055119 B. Wing 02/09/2025

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

West Pico Terrace Healthcare & Wellness Centre LP 6070 W. Pico Boulevard Los Angeles, CA 90035

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

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

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

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43454 potential for actual harm Based on observation, interview and record review, the facility failed to Residents Affected - Some 1. Ensure one of 12 sampled residents (Resident 4) who tested negative for coronavirus (COVID-19 - an infectious disease that can cause respiratory illness in humans) was not cohorted with a resident who tested positive with COVID-19.

2. Ensure the Physician's order for transmission-based precaution was updated for Resident 30.

These deficient practices had the potential to transmit infectious diseases and increase the risk of infection to

the residents, staff, and visitors.

Findings:

1a. A review of the Admission Record indicated Resident 4 was originally admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including pneumonia (lung infection that inflames air sacs with fluid or pus), acute respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), hemiplegia and hemiparesis (total paralysis of the arm, leg, and trunk on the same side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting left dominant side.

A review of the Minimum Data Set (MDS - resident assessment tool) dated 12/20/2024, indicated Resident 4's cognitive (relating to mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS indicated Resident 4 required maximal to total dependent from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).

During a concurrent observation and interview with Resident 4 on 2/7/2025 at 7:13 p.m., Resident 4 was cohorted and placed in the same room with Resident 29. Resident 4 stated, she tested negative for COVID-19.

1b. A review of the Admission Record indicated Resident 29 was originally admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), and muscle wasting and atrophy (characterized by a significant shortening of the muscle fibers and

a loss of overall muscle mass).

A review of the MDS dated [DATE REDACTED], indicated Resident 29's cognitive skills for daily decisions were severely impaired.

A review of Resident 29's COVID-19 antigen (generally a protein on the surface of a virus) test dated 2/6/2025, indicated, Resident 29 tested positive for COVID-19 infection.

A review of facility's census on 2/7/2025, 2/8/2025, 2/9/2025 indicated, Resident 4 had been placed in a room cohorted with Resident 29.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 34 055119 Department of Health & Human Services Printed: 09/09/2025 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 055119 B. Wing 02/09/2025

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

West Pico Terrace Healthcare & Wellness Centre LP 6070 W. Pico Boulevard Los Angeles, CA 90035

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

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

F 0880 During an interview with Registered Nurse 1 (RN 1) on 2/8/2025 at 4:23 p.m., RN 1 stated, Resident 29 tested positive for COVID-19 and Resident 4 tested negative. RN 1 stated, both residents (Resident 4 and Level of Harm - Minimal harm or Resident 29) were placed in the same room but there were no documentations to indicate the reason why potential for actual harm they (facility) did not separate Resident 4 and Resident 29. RN 1 further stated, Resident 4 did not want to move to another room, but there were no documentations for explanation of the risk of Resident 29 refusing Residents Affected - Some to be moved. RN 1 stated, if a resident with negative COVID test is placed with a resident who is tested positive for COVID-19, it places the resident at risk of transmitting the infection to another resident.

During an interview with Infection Preventionist (IPN) on 2/9/2024 at 3:10 p.m., IPN stated Resident 4 was not moved to another room because the resident refused to be moved. IPN stated, there were no documentation that Resident 4 was offered to be moved as her roommate, Resident 29 who tested positive with COVID-19. IPN stated, this (practice) placed other residents at risk of contracting COVID-19 infection.

A review of the facility's Public Health Letter titled, Viral Respiratory Illness Outbreak Notification Letter, dated 2/7/2025 indicated, Based on the preliminary investigation, the Department of Public Health required that the following control measures and actions be implemented, as applicable to the setting: identify symptomatic individuals so that they can be separated from those affected by the illness.

A review of the facility's policy and procedure (P&P) titled, Management of COVID-19, reviewed date 6/20/2024 indicated, Centers will have a plan based on CDC/CMS/State/local recommendation to prevent transmission, such as having a dedicated space in the facility for cohorting and managing care for patients with COVID-19 . Cohorting of patient within the Center will be in accordance with the Cohorting Policies.

A review of Centers for Disease Control and Prevention (CDC - national public health agency of the United States) titled, Infection Control Guidance: SARS-SoV-2, dated 12/2023, indicated, Placement of residents with suspected or confirmed SARS-CoV-2 infection: Ideally, residents should be placed in a single-person room as described.

2. A review of the Admission Record indicated Resident 30 was originally admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including acute bronchospasm (a sudden narrowing of the airways [bronchi] in the lungs, caused by the contraction of muscles lining the airways), pulmonary embolism (a blood clot gets stuck in an artery in the lung, blocking blood flow to part of the lung), Type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure).

A review of the MDS dated [DATE REDACTED], indicated Resident 30's cognitive skills for daily decisions was intact. The MDS indicated Resident 30 required set-up assistance from staff for ADLs.

A review of Resident 30's Order Summary Report dated 1/29/2025, indicated the physician ordered for the resident to be on, Contact/droplet precaution (contact precautions are used for patients with infections that can be transmitted by contact, while droplet precautions are used for patients with infections that can be transmitted by droplet).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 34 055119 Department of Health & Human Services Printed: 09/09/2025 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 055119 B. Wing 02/09/2025

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

West Pico Terrace Healthcare & Wellness Centre LP 6070 W. Pico Boulevard Los Angeles, CA 90035

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 a concurrent observation and interview with Resident 30 on 2/7/2025 at 6:03 p.m., Resident 30 stated, he was having some shortness of breath (SOB) and on oxygen therapy. Resident 30 was observed in Level of Harm - Minimal harm or a room with no transmission-based precaution (TBP) signage outside his door; there were no personal potential for actual harm protective equipment (PPE-a barrier precaution which includes the use of gloves, gown, mask, face shield, when anticipating coming in contact with blood, body fluids or other communicable toxins or agents) Residents Affected - Some observed outside the door for staff and visitors to use.

During an interview with RN 1 on 2/8/2025 at 4:23 p.m., RN 1 stated, Resident 30 was on TBP room while he was taking antibiotic (ABX) for pneumonia. RN 1 reviewed Resident 30's medical record and confirmed, the Physician's order for contact/droplet precaution is still in place. RN 1 stated, it (the precaution) should have been discontinued as Resident 30 was done with ABX therapy.

During an interview with IPN on 2/9/2024 at 9:16 a.m., IPN stated Resident 30 was no longer on TBP room, and they should have discontinued the order for precaution. IPN stated, she did not discontinue the order timely after physician had ordered to discontinue the TBP room.

A review of the facility's P&P titled, Infection Control- Policies & Procedures, reviewed date 6/20/2024, indicated, The facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 34 055119 Department of Health & Human Services Printed: 09/09/2025 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 055119 B. Wing 02/09/2025

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

West Pico Terrace Healthcare & Wellness Centre LP 6070 W. Pico Boulevard Los Angeles, CA 90035

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

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

F 0912 Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45528

Residents Affected - Some Based on observation, interview and record review, the facility failed to provide at least 80 square feet (sq. ft. -unit of measurement for space) per resident in multiple resident bedrooms for three (3) of 23 resident rooms (rooms [ROOM NUMBER]).

This deficient practice had the potential to result in inadequate usable living space for all the residents and working space for the health caregivers, which could affect the quality of care and the quality of life for the residents.

Findings:

A review of the Request for Room Size Waiver letter submitted by the Administrator, dated 2/9/2025, indicated three (3) resident rooms in the facility do not meet the requirement of at least 80 square feet per resident per federal regulation. The letter also indicated the rooms do not pose any kind of risk to the care and services the facility provides to the residents. Each room has access to the outside and provides ample sunlight and ventilation.

The following rooms provided are less than 80 sq.ft. pr resident:

Room # Room Size Floor Area (sq.ft.) #of beds

7 19.1 x 10.91 217.21 3

14 20.1 x 10.83 217.68 3

15 20 x 11 220 3

According to the federal regulation, the minimum square footage for a two bedroom is at least 160 sq. ft and three bedroom is at least 240 sq. ft.

During the recertification Survey on 2/9/2025, staff interviews indicated there were no concerns regarding the size of the rooms.

During multiple observations of the resident's rooms from 2/7/2025 to 2/9/2025, the residents had ample space to move freely inside the rooms. There were sufficient spaces to provide freedom of movement for the residents and for nursing staff to provide care to the residents. There were also sufficient spaces for bedside tables, side tables and resident care equipment.

During a concurrent observation and interview on 2/8/2025, at 4:26 p.m., the maintenance Supervisor (MS) used tape measurer to measure the size of the room from the window to the door for the length, then measured from wall to the start of the closet horizontally for the width to determine the room area. The MS stated, this is how I measure to verify the size of the rooms.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 34 055119 Department of Health & Human Services Printed: 09/09/2025 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 055119 B. Wing 02/09/2025

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

West Pico Terrace Healthcare & Wellness Centre LP 6070 W. Pico Boulevard Los Angeles, CA 90035

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

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

F 0912 During an interview on 2/8/2025 at 5:52 p.m., the [NAME] President of Operations (VPO) stated the facility submitted a written request for the continued room waiver although the room sizes do not impede resident Level of Harm - Potential for care. minimal harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 34 055119