Providence Holy Cross Med Ctr D/p Snf

F-F658

Findings:

a. During a review of Resident 35's Face Sheet, the Face Sheet indicated the facility originally admitted the resident on 11/27/2023 and readmitted in the facility on 7/10/2024 with diagnoses including craniotomy (a major type of brain surgery where the surgeon will remove and replace part of the skull to access and treat a problem within the brain, hypertension (HTN - also known as high blood pressure), and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body).

During a review of Resident 35's History and Physical (H&P) dated 7/12/2024, the H&P indicated Resident 35 had the presence of tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck and was non-verbal (not speaking).

During a review of Resident 35's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/28/2025, the MDS indicated Resident 35 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS further indicated Resident 35 received anticoagulant.

During a review of Resident 35's physician's order, the physician's order dated 1/8/2025 indicated heparin sodium injection (porcine) solution 5000 units per milliliter (units/ml - a unit of measurement) 5000 units subcutaneously every 12 hours for DVT (deep vein thrombosis - a blood clot that forms in one or more of the deep veins in the body, usually in the legs causing leg pain or swelling) prophylaxis.

During a review of Resident 35's care plan (CP) on thrombolytic therapy (the use of medications to dissolve blood clots) last revised on 3/2/2025 with a target date of 5/28/2025, the CP indicated to frequently monitor peripheral perfusion to address complications early as one of the interventions to prevent and manage risk of bleeding.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 52 555074 Department of Health & Human Services Printed: 09/03/2025 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 555074 B. Wing 03/27/2025

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

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

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

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

F 0760 During a concurrent interview and record review on 3/25/2025 at 11:05 am., reviewed Resident 35's physician's order, subcutaneous administration sites for heparin from 1/8/2025 to 3/25/2025, and the MDS Level of Harm - Minimal harm or with the Minimum Data Set Nurse (MDSN). The MDSN stated Resident 35 received heparin, had a potential for actual harm physician's order for heparin, and were administered as follows:

Residents Affected - Some Heparin 5000 units/ml injection 5000 units:

- 1/20/2025 5:51 a.m. left upper quadrant - LUQ

- 1/20/2025 5:03 p.m. LUQ

- 3/2/2025 6:22 p.m. LUQ

- 3/3/2025 5:14 a.m. LUQ

- 3/7/2024 6:58 a.m. right upper quadrant - RUQ

- 3/7/2025 5:39 a.m. RUQ

- 3/23/2025 5:15 a.m. LUQ

- 3/23/2025 17:32 LUQ

The MDSN stated administration sites for insulin and anticoagulants such as heparin should be rotated per standards of practice and manufacture's guideline to prevent hardening or lumps in the skin. The MDSN stated the list of administration sites for the heparin were not rotated. The MDSN stated Resident 35's administration sites should have been rotated to prevent pain, redness, irritation, and lumps on the resident's skin. The MDSN stated not rotating the administration sites for the insulin is not following the standards of practice and manufacturer's guideline and can be considered a medication error which may lead to an adverse reaction to the medicine.

During a concurrent interview and record review on 3/27/2025 at 5:00 p.m. with Registered Nurse (RN) 8, RN 8 stated the location of administration sites for Resident 35's heparin were not rotated. RN 8 stated the nurses are supposed to rotate heparin administration sites according to standards of practice, and as indicated in the manufacturer's guideline. RN 8 stated Resident 35's administration sites for heparin should have been rotated to prevent adverse effects such as bruising, skin irritation, skin pits, lipodystrophy and amyloidosis which can affect absorption of the medication. RN 8 stated not rotating the administration sites for the heparin is not following the standards of practice and manufacturer's guideline and can be considered

a medication error.

During a review of the facility-provided manufacturer's guideline for heparin sodium injection solution, dated 1/2022, the manufacturer's guideline indicated to use a different site for each injection. The manufacturer's guideline further indicated injection site irritation is one of the most common adverse reactions for the use of heparin.

During a review of the facility's policy and procedure (P&P) titled, Medication Administration and Monitoring (Sub Acute), last reviewed on 3/2025, the P&P indicated the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 52 555074 Department of Health & Human Services Printed: 09/03/2025 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 555074 B. Wing 03/27/2025

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

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

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

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

F 0760 - Healthcare providers administering medications are responsible for knowing and understanding the dosage, indications, side effects and precautions/warnings of the medications being administered. Level of Harm - Minimal harm or potential for actual harm - Injection sites for subcutaneous and intramuscular administration must be rotated.

Residents Affected - Some During a review of the facility's P&P titled, Medication Error Reporting, last reviewed on 3/10/2025, the P&P indicated a medication event/error is defines as any preventable event (actual/potential) that may cause or lead to inappropriate medication use and/or patient harm while medication is in the control of health care professional, patient or consumer. Medication errors can occur within any of the following steps in the medication management process including prescribing, order communication, product labeling, packaging and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use.

b. During a review of Resident 42's Face Sheet, the Face Sheet indicated the facility originally admitted the resident on 9/4/2024 and readmitted in the facility on 12/20/2024 with diagnoses including history of stroke (loss of blood flow to a part of the brain), tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck, and ventilator-dependent respiratory failure (condition when a patient's lungs cannot breath on their own and required a machine to help breathe).

During a review of Resident 42's History and Physical (H&P) dated 12/22/2024, the H&P indicated Resident 42 was awake and alert but did not indicate the resident's capacity to understand and make decisions.

During a review of Resident 42's MDS, dated [DATE REDACTED], the MDS indicated Resident 42 was able to make his needs known and able to understand others. The MDS further indicated Resident 42 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required substantial/maximal assistance to total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 42 received insulin.

During a review of Resident 42's physician's order, the physician's order dated 2/24/2025 indicated insulin glargine-yfgn (a long-acting insulin) injection vial eight (8) units (a unit of measurement) at bedtime for diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing).

During a review of Resident 42's care plan (CP) on hyperglycemia last revised on 3/2/2025 with a target date of 7/31/2025, the CP indicated to provide pharmacologic therapy (drug or medication therapy) to maintain blood sugar levels within targeted range.

During a concurrent interview and record review on 3/25/2025 at 11:05 am., reviewed Resident 42's physician's order, subcutaneous administration sites for insulin glargine from 2/24/2025 to 3/25/2025, and

the MDS with the Minimum Data Set Nurse (MDSN). The MDSN stated Resident 42 had a physician's order for insulin glargine, and were administered as follows:

Insulin glargine-yfgn injection 8 units:

- 3/12/2024 5:35 p.m. left lower quadrant - LLQ

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 52 555074 Department of Health & Human Services Printed: 09/03/2025 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 555074 B. Wing 03/27/2025

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

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

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

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

F 0760 - 3/13/2025 5:34 p.m. LLQ

Level of Harm - Minimal harm or - 3/17/2025 5:27 p.m. left upper arm - LUA potential for actual harm - 3/18/2025 5:51 p.m. LUA Residents Affected - Some

The MDSN stated administration sites for insulin and anticoagulants should be rotated per standards of practice and manufacture's guideline to prevent hardening or lumps in the skin. The MDSN stated the list of administration sites for Resident 42's insulin glargine were not rotated. The MDSN stated Resident 42's administration sites should have been rotated to prevent pain, redness, irritation, and lumps on the resident's skin. The MDSN stated not rotating the administration sites for the insulin is not following the standards of practice and manufacturer's guideline and can be considered a medication error.

During a concurrent interview and record review on 3/27/2025 at 5:00 p.m. with Registered Nurse (RN) 8, RN 8 stated the location of administration sites for Resident 42's insulin glargine were not rotated. RN 8 stated the nurses are supposed to rotate insulin administration sites according to standards of practice, and as indicated in the manufacturer's guideline. RN 8 stated Resident 42's administration sites for insulin glargine should have been rotated to prevent adverse effects such as bruising, skin irritation, skin pits, lipodystrophy and amyloidosis which can affect absorption of the insulin. RN 8 stated not rotating the administration sites for the insulin is not following the standards of practice and manufacturer's guideline and can be considered a medication error.

During a review of the facility-provided manufacturer's guideline for insulin glargine (rDNA origin) 100 units per milliliter (units/ml - a unit of measurement) three (3) ml pen dated 8/26/2022, the manufacturer's guideline indicated to change (rotate) the injection site for each injection and to inject under the skin of the stomach area, buttocks, upper legs or upper arms.

During a review of the facility's P&P titled, Medication Administration and Monitoring (Sub Acute), last reviewed on 3/2025, the P&P indicated the following:

- Healthcare providers administering medications are responsible for knowing and understanding the dosage, indications, side effects and precautions/warnings of the medications being administered.

- Injection sites for subcutaneous and intramuscular administration must be rotated.

During a review of the facility's P&P titled, Medication Error Reporting, last reviewed on 3/10/2025, the P&P indicated a medication event/error is defines as any preventable event (actual/potential) that may cause or lead to inappropriate medication use and/or patient harm while medication is in the control of health care professional, patient or consumer. Medication errors can occur within any of the following steps in the medication management process including prescribing, order communication, product labeling, packaging and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 52 555074 Department of Health & Human Services Printed: 09/03/2025 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 555074 B. Wing 03/27/2025

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

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

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 43988 Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services during the inspection of one (1) of three (3) medication carts (Medication Cart 1) reviewed during the Medication Storage and Labeling task by failing to discard Resident 1's medication in the bubble pack (a packaged container with compartments that can contain medications) with a broken seal and covered with paper tape.

This deficient practice had the potential for medication error and contaminate medications stored inside the medication cart.

Findings:

During a concurrent observation and interview, on 3/26/2025, at 8:33 a.m., during an inspection of Medication Cart 1, in the presence of Registered Nurse (RN) 8, RN 8 confirmed and stated Resident 1's cyanocobalamin (a manufactured version of vitamin B12 used to treat and prevent vitamin B12 deficiency anemia [low levels of this vitamin in the body]) had a broken seal and was stored in Medication Cart 1. RN 8 stated the process prior to dispensing a medication from a bubble pack includes the licensed nurses (LNs) comparing the medication label in the bubble pack with the medication administration record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) first. RN 8 stated if a medication was dispensed by accident from the bubble pack, the medication should be discarded immediately at the designated bin inside the medication room and not taped back in the bubble pack. RN 8 stated the seal from Resident 1's bubble pack was broken and covered with clear plastic tape. RN 8 stated the medications for slot numbers 5 and 13 should have been discarded once removed from the bubble pack and not taped back as the medication had been contaminated. RN 8 stated it could not be the right medication that was placed back in the bubble pack and placed the Resident 1 at risk for receiving the incorrect medication which can be a medication error.

During an interview, on 3/27/2025, at 5:30 p.m., with the Nurse Manager (NM), the NM stated she was made aware by RN 8 of the issue with the cyanocobalamin. The NM stated the cyanocobalamin should have been discarded in the designated bin inside the medication room if dispensed by accident. The NM stated the LN are supposed to compare the medication label in the bubble pack with the MAR first prior to dispensing a medication from the bubble pack. The NM stated dispensing a medication and taping it back to the bubble pack is not an acceptable practice as the medication was already contaminated, the nurses would not know if the correct medicine was placed back in the bubble pack, and the resident receives the correct medication.

During a review of the facility's policy and procedure (P&P) titled, Storage of Medications, last reviewed 3/10/2025, the P&P indicated:

- Medications and biologicals are stored safely, securely, and properly.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 52 555074 Department of Health & Human Services Printed: 09/03/2025 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 555074 B. Wing 03/27/2025

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

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

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 - Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for Level of Harm - Minimal harm or medication disposal, and reordered from the pharmacy if a current order exists. potential for actual harm - Medication storage conditions are monitored on a routine basis and corrective action are taken if problems Residents Affected - Few are identified.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 52 555074 Department of Health & Human Services Printed: 09/03/2025 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 555074 B. Wing 03/27/2025

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

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

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

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

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

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44244

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

1. Ensure towels were stored in clean towel bins, sanitation buckets, or dirty towel bins when not in use.

2. Ensure food items in the walk-in Refrigerators #2 and #5 were labeled according to facility policy.

3. Ensure the personal property of staff was not stored in the kitchen area next to an uncovered serrated knife and food items.

4. Ensure Refrigerator #10 and the Subacute Resident Refrigerator/Freezer temperatures were maintained per facility policy and procedure.

These deficient practices had the potential to result in harmful bacterial growth and cross contamination (the process by which bacteria, microorganisms, or chemicals are unintentionally transferred from one substance or object to another, with harmful effect) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 10 of 45 medically compromised residents who received food and ice from the kitchen.

Findings:

a. During an Initial Kitchen Tour, on [DATE REDACTED], at 8 a.m., with the Interim Director of Hospitality Services (IDHS) and Food Service Attendant 1 (FSA 1), the IDHS stated the facility uses white towels to sanitize the kitchen.

The IDHS stated all towels should only be stored in clean towel bins prior to use, red sanitizer buckets when

in use, or dirty towel bins after use. The IDHS stated no towels should be left out in the tray line area to prevent cross contamination from one surface to another while staff is performing tasks in the kitchen. Observed the following in the tray line area:

1. A white towel placed on the top of FSA 1's black rolling cart. The IDHS stated the towel was used and should not be on the cart. FSA 1 stated at approximately 6:30 a.m., FSA 1 used the towel and placed the dirty towel on the cart. FSA 1 stated she should not have placed the dirty towel on the cart. FSA 1 stated dirty towels should not be left on carts because the towel could be soiled with bacteria that could potentially contaminate the tray line area. FSA 1 stated there was no reason why she left the towel on the cart and stated she should not have.

2. Two white towels placed on an unattended black rolling cart. The IDHS stated she did not know if the towels were used. The IDHS stated the towels should not be placed on the unattended cart. The IDHS removed the towels and placed them in the dirty towel bin. The IDHS stated the towels could be dirty and cause cross contamination resulting in foodborne illness in residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 52 555074 Department of Health & Human Services Printed: 09/03/2025 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 555074 B. Wing 03/27/2025

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

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

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

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

F 0812 During a concurrent interview and record review, on [DATE REDACTED], at 1:35 p.m., with the Clinical Nutrition Manager (CNM), the facility provided Health and Safety Code (HSC) regarding equipment, utensils, and linens was Level of Harm - Minimal harm or reviewed. The CNM stated the facility does not have a specific policy regarding the use of towels in the potential for actual harm kitchen, but it is a standard of practice to never keep towels in the kitchen area unless they are in a sanitization bucket. The CNM reviewed the HSC and stated the kitchen staff did not follow the HSC when Residents Affected - Some towels were left out in the kitchen.

During a review of the facility provided HSC document titled, Article 5. Linens, dated effective [DATE REDACTED], the HSC indicated wiping cloths that are used repeatedly are held in a sanitizing solution of an approved concentration. Working containers of sanitizing solutions for storage of in-use wiping cloths shall be used in a manner to prevent contamination of food, equipment, utensils, and linens. Soiled linens shall be kept in receptacles and transported to prevent contamination of food, clean equipment, and clean utensils.

During a review of the facility policy and procedure (P&P) titled, Safety and Sanitation Standards, effective date [DATE REDACTED], the P&P indicated safety and sanitation standards are followed to ensure the provision of safe food to the customers. Each employee is responsible for maintaining a clean and safe work area throughout their shift.

b. During an Initial Kitchen Tour, on [DATE REDACTED], at 8 a.m., with the IDHS and FSA 1, the IDHS stated staff have

a locker to store their personal belongings and personal knives when not in use. The IDHS stated no personal items should be in the kitchen because there is a potential of cross contamination resulting in foodborne illness in residents. The top shelf of FSA 1's black rolling cart contained a box of substitute sugar packets, a box of seasoning packets, a cellphone, a wireless headphone case, and a serrated knife. The IDHS stated FSA 1 should have stored the cell phone and headphone case in FSA 1's locker. The IDHS stated FSA 1's knife should have been covered and securely stored in the designated storage area when not

in use, but FSA 1 stored the uncovered knife on the cart next to FSA 1's personal items. FSA 1 stated the cell phone and headphone case belonged to her and personal items should not be stored in the kitchen. FSA 1 stated she uses the knife to cut fruit and the knife should not be stored uncovered and next to personal items because the phone and headphone case could contaminate the knife and other food items with bacteria. FSA 1 stated there was no reason why she stored the knife and personal items in the cart.

During a concurrent interview and record review, on [DATE REDACTED], at 1:35 p.m., the CNM reviewed the facility provided HSC regarding personal belongings. The CNM stated some kitchen staff bring personal knives to use in the facility kitchen and the knives should be stored properly when not in use. The CNM stated all cell phones and headphone cases should always be stored in the staff members locker and not in the kitchen or tray line area. The CNM stated the facility did not have a specific policy regarding personal items and uncovered knives in the kitchen, but it was a standard of practice based on the HSC. The CNM stated FSA 1 did not follow the facility practice when the knife, cell phone, and headphone case were stored on the cart in

the tray line area.

During a review of the facility provided HSC document titled, Article 4. Employee Storage Areas dated effective [DATE REDACTED], the HSC indicated lockers or other suitable facilities shall be located in a designated room or area where contamination of food, equipment, utensils, and linens cannot occur. No personal effects are stored in any area used for the storage or preparation of food. A safety knife holder shall be provided to avoid loose storage of knives.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 52 555074 Department of Health & Human Services Printed: 09/03/2025 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 555074 B. Wing 03/27/2025

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

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

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

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

F 0812 During a review of the facility P&P titled, Dress Code, effective date [DATE REDACTED], the P&P indicated the purpose of the P&P was to avoid contamination of food. As appropriate and available, a locker will be assigned for Level of Harm - Minimal harm or employee use. Cell phones are not permitted at workstations. potential for actual harm

During a review of the facility P&P titled, Safety and Sanitation Standards, effective date [DATE REDACTED], the P&P Residents Affected - Some indicated safety and sanitation standards are followed to ensure the provision of safe food to the customers. Each employee is responsible for maintaining a clean and safe work area throughout their shift.

c. During an Initial Kitchen Tour, on [DATE REDACTED], at 8 a.m., with the IDHS, observed the facility walk in refrigerators with the IDHS. The IDHS stated the facility labels food items that are stored in the refrigerators to facilitate the first in, first out method (rotation method used to minimize waste and ensure food safety by preventing spoilage) and to ensure expired food is discarded and not served to residents. The IDHS stated it was important to label and discard expired food because there is a potential that expired foods served to resident may cause foodborne illness. Observed the following:

1. In Refrigerator #5, two unopened, prepackaged egg salad sandwiches by Manufacture 1(Mfr. 1), labeled , d+[DATE REDACTED]. The IDHS stated the sandwiches expired on [DATE REDACTED] and should not have been stored in the refrigerator available to be served to residents. The IDHS stated the staff should have discarded the expired sandwiches and they did not. The IDHS stated when the expired sandwiches were left in the refrigerator, there was a potential that the expired sandwiches could be served to residents causing illness.

2. In Refrigerator # 5, there was one unlabeled large pan of cooked meat that was partially uncovered with

the contents exposed to air. The IDHS stated the pan contained leftover chicken breasts and was unlabeled.

The IDHS stated she did not know when the pan was placed in the fridge because it was not labeled. The IDHS stated it was important to label leftovers with the item contents and date of expiration to ensure staff knows what the food is and to ensure expired food is not served to residents.

3. In Refrigerator #2, one opened container labeled sour cream. The IDHS stated the expiration date on the container was not legible. The IDHS stated the facility uses the expiration on the container to know when to discard the sour cream. The IDHS stated because the expiration date was not legible, she did not know if the sour cream was expired. The IDHS stated if an expiration date is not legible then the sour cream should be thrown out.

During a concurrent interview and record review, on [DATE REDACTED], at 1:35 p.m., the CNM reviewed the facility P&P regarding food storage labeling and leftovers. The CNM stated the kitchen floor stocking staff should discard any unlabeled, illegibly labeled, or expired foods from the refrigerators to ensure expired food that may be sour, rotted, or moldy is not served to residents. The CNM stated when expired food is served to residents it may affect the nutritional value of food and cause the residents to not feel well.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 52 555074 Department of Health & Human Services Printed: 09/03/2025 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 555074 B. Wing 03/27/2025

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

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

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

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

F 0812 During a review of the facility P&P titled, Label and Dating, effective date [DATE REDACTED], the P&P indicated the Food and Nutrition Services shall ensure that foods are labeled, dated, and stored appropriately. The Level of Harm - Minimal harm or purpose of the P&P was to ensure proper storage and safety of the department's food supply. The following potential for actual harm procedures and checks are done regularly to prevent any possible contamination or spoilage of food:

Residents Affected - Some i. Caregivers are to remove any expired item and ensure that foods are safely stored.

ii. All food supplies shall be rotated on a first-in, first-out, basis. This will ensure the oldest product is used first.

iii. The pull date, is the last date that an item can be used. The product will be pulled on the morning following its pull date, and disposed of. Items prepared on premises, will carry a pull date to ensure maximum freshness. Where items are pull-dated by the manufacture, items will be pulled accordingly.

iv. Products will be dated via the following acceptable mechanisms.

a) Label with the following information will be used to label and date foods for holding and storage:

i) Item name

ii) Use by date (pull date)

iii) Employee signature

v. All prepared items will receive a three day pull date.

During a review of the facility P&P titled, Label and Dating, Attachment A; Pull Dates, effective date [DATE REDACTED],

the P&P attachment indicated the following pull dates:

Product: sour cream has a pull date of the date on the container.

Product: cooked chilled chicken has a pull date of three days.

Product: Mfr. 1 Sandwiches have a pull date of two days.

During a review of the facility P&P titled, Leftovers, effective date [DATE REDACTED], the P&P indicated leftover food is given a three day pull date to ensure proper usage, storage, and safety of the department leftover's food. Food portions not utilized in the service of a meal will be refrigerated in a shallow covered container labeled and dated with a three day pull date.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 52 555074 Department of Health & Human Services Printed: 09/03/2025 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 555074 B. Wing 03/27/2025

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

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

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 d.1. During an Initial Kitchen Tour, on [DATE REDACTED], at 8 a.m., with the IDHS, observed the facility walk in refrigerators with the IDHS. The IDHS stated the facility maintains refrigerators at an acceptable temperature Level of Harm - Minimal harm or range of 32 to 41 degrees Fahrenheit ( F, a unit of measurement for temperature) to ensure the quality of the potential for actual harm food and to prevent food borne illness in residents . The IDHS stated refrigerator # 10 is used during tray line and the thermometer indicated the refrigerator was 41 degrees. The IDHS reviewed Refrigerator #10's Residents Affected - Some Temperature Log for ,d+[DATE REDACTED] and noted the refrigerator was out of the acceptable temperature range for

the p.m. shift (evening shift) on the following dates:

- On [DATE REDACTED], the temperature was 42 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 48 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 42 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 42 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 44 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 44 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 44 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 44 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 44 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 45 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 44 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 44 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 42 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 46 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 52 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 50 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 50 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 42 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 42 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 44 F, no corrective actions/comments are indicated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 52 555074 Department of Health & Human Services Printed: 09/03/2025 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 555074 B. Wing 03/27/2025

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

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

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 - On [DATE REDACTED], the temperature was 42 F, no corrective actions/comments are indicated.

Level of Harm - Minimal harm or The IDHS further stated she did not know why Refrigerator #10 was out of the acceptable temperature range potential for actual harm only on the p.m. shift.

Residents Affected - Some During a concurrent interview and record review, on [DATE REDACTED], at 10:45 a.m., with the CNM, the facility provided Work Order email, dated [DATE REDACTED], and Refrigerator #10's Temperature Log, for ,d+[DATE REDACTED], were reviewed. The CNM noted Refrigerator #10 was out of the acceptable temperature range for the p.m. shift (evening shift) on the following dates:

- On [DATE REDACTED], the temperature was 44 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 42 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 42 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 44 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 42 F, no corrective actions/comments are indicated.

The CNM further stated, on [DATE REDACTED], at 6:43 p.m., the evening kitchen supervisor entered a work order indicating Refrigerator #10 was out of the temperature control limits and needed service. The CNM stated there was no follow up to the work order. The CNM stated the refrigerator was taking too long to reach acceptable temperature ranges after the evening tray line and should have been removed from the kitchen service, but it was not removed. The CNM stated a refrigerator should consistently provide an acceptable temperature range for food safety. The CNM stated the food safety temperature zone is below 41 degrees to prevent bacterial growth. The CNM stated when Refrigerator #10 was not maintained at a temperature between 32 to 41 F, it could have potentially resulted in bacterial growth causing food borne illnesses in residents.

During a review of the facility P&P titled, Refrigerator/Freezer Temperature Logs, effective date [DATE REDACTED], the P&P indicated all refrigerators and freezers must be monitored and the temperature documented to ensure

the proper storage of food. The purpose of the policy was to ensure that food is safe and is being held n compliance with public health regulations. Temperatures will be checked daily in the main kitchen and patient units. All temperatures are documented on the appropriate temperature log with the recorder's initials. Acceptable temperature ranges are 32 to 41 F for refrigerators and below 0 F for freezers. When refrigerators and freezer temperatures are out of range, the following action step occur:

a) Circle the out-of-range temperature in red ink

b) Check the internal temperature of the food contained in the affected refrigerator and/or freezer, if the foods' temperature is out of the acceptable range, discard.

c) Write an action plan on the temperature log, if more room is needed, turn the temperature log over and

record the date and remainder of the action plan.

d) Contact plant operations for repair as indicated

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 52 555074 Department of Health & Human Services Printed: 09/03/2025 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 555074 B. Wing 03/27/2025

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

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

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 e) Follow up to ensure the action plan has been completed.

Level of Harm - Minimal harm or d.2. During a Subacute Kitchen Tour, on [DATE REDACTED], at 9 a.m., with the Clinical Educator (CE), observed the potential for actual harm subacute refrigerators with the CE. The CE stated the Subacute refrigerator was maintained and monitored by the facility kitchen staff. The CE stated the acceptable temperature range for the refrigerator was between Residents Affected - Some 32 and 41 F. The CE reviewed the Subacute Refrigerator's Temperature Log for ,d+[DATE REDACTED] and noted the refrigerator was out of the acceptable temperature range on the following dates:

- On [DATE REDACTED], the temperature was 20 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 24 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 25 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 30 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 28 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 30 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 25 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 30 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 30 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 30 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 30 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 30 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 30 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 25 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 25 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 25 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 30 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 30 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 30 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was 30 F, no corrective actions/comments are indicated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 52 555074 Department of Health & Human Services Printed: 09/03/2025 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 555074 B. Wing 03/27/2025

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

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

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 - On [DATE REDACTED], the temperature was 30 F, no corrective actions/comments are indicated.

Level of Harm - Minimal harm or During a concurrent interview and record review, on [DATE REDACTED], at 1:35 p.m., with the CNM, the CNM reviewed potential for actual harm the Subacute Refrigerator's Temperature Log for ,d+[DATE REDACTED]. The CNM stated the CNM was made aware the Subacute refrigerator was out of acceptable temperature range with no corrective actions indicated. The Residents Affected - Some CNM stated the Subacute freezer log also indicated the freezer was out of the acceptable temperature range of below 0 F on the following dates:

- On [DATE REDACTED], the temperature was +10 F, no corrective actions/comments are indicated.

- On [DATE REDACTED], the temperature was +10 F, no corrective actions/comments are indicated.

The CNM further stated the importance of reporting when the temperature is out of range is to ensure the refrigerator/freezer is checked and functioning properly. The CNM stated when the subacute refrigerator's temperature was too low it could have potentially resulted in quality issues like the liquids freezing. The CNM stated residents must be served the intended appropriate texture and consistency of foods. The CNM stated when the items do not remain frozen in the freezer, it may result in quality issues from foods defrosting and refreezing.

During a review of the facility P&P titled, Refrigerator/Freezer Temperature Logs, effective date [DATE REDACTED], the P&P indicated all refrigerators and freezers must be monitored and the temperature documented to ensure

the proper storage of food. The purpose of the policy was to ensure that food is safe and is being held in compliance with public health regulations. Temperatures will be checked daily in the main kitchen and patient units. All temperatures are documented on the appropriate temperature log with the recorder's initials. Acceptable temperature ranges are 32 to 41 F for refrigerators and below 0 F for freezers. When refrigerators and freezer temperatures are out of range, the following action step occur:

a) Circle the out-of-range temperature in red ink

b) Check the internal temperature of the food contained in the affected refrigerator and/or freezer, if the foods' temperature is out of the acceptable range, discard.

c) Write an action plan on the temperature log, if more room is needed, turn the temperature log over and

record the date and remainder of the action plan.

d) Contact plant operations for repair as indicated

e) Follow up to ensure the action plan has been completed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 52 555074 Department of Health & Human Services Printed: 09/03/2025 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 555074 B. Wing 03/27/2025

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

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38552 potential for actual harm Based on interview and record review, the facility failed to fully develop and implement an antibiotic Residents Affected - Many (antimicrobial, medicine that inhibits the growth of or destroys microorganisms) stewardship program (ASP- a coordinated program that promotes the appropriate use of drugs used to treat infections, including antibiotics as a part of its overall Infection Prevention and Control Program (IPCP) for one of six sampled residents (Resident 3) reviewed under Infection Control facility task by:

a. Failing to establish protocols to identify signs and symptoms of infections among residents to assess whether they met evidence-based national standard criteria for initiating antibiotic treatment

b. Failing to identify Resident 3's use of levofloxacin (antibiotic) indicated for urinary tract infection (UTI- an infection in the bladder/urinary tract).

These deficient practices had the potential to result in increased risk of inappropriate antibiotic use, potentially leading to adverse outcomes (complications arising from an intervention or condition) such as antibiotic resistance (the acquired ability of bacterial pathogens to withstand the effects of antimicrobial agents, reducing treatment efficacy) to Resident 3.

Cross-reference

F-F760

Findings:

a. During a review of Resident 35's Face Sheet, the Face Sheet indicated the facility originally admitted the resident on 11/27/2023 and readmitted in the facility on 7/10/2024 with diagnoses including craniotomy (a major type of brain surgery where the surgeon will remove and replace part of the skull to access and treat a problem within the brain), hypertension (HTN - also known as high blood pressure), and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body).

During a review of Resident 35's H&P dated 7/12/2024, the H&P indicated Resident 35 had the presence of tracheostomy and was non-verbal (not speaking).

During a review of Resident 35's MDS, dated [DATE REDACTED], the MDS indicated Resident 35 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS further indicated Resident 35 received anticoagulant.

During a review of Resident 35's physician's order, the physician's order dated 1/8/2025 indicated heparin sodium injection (porcine) solution 5000 units per milliliter (units/ml - a unit of measurement) 5000 units subcutaneously every 12 hours for DVT (deep vein thrombosis - a blood clot that forms in one or more of the deep veins in the body, usually in the legs causing leg pain or swelling) prophylaxis.

During a review of Resident 35's care plan (CP) on thrombolytic therapy (the use of medications to dissolve blood clots) last revised on 3/2/2025 with a target date of 5/28/2025, the CP indicated to frequently monitor peripheral perfusion to address complications early as one of the interventions to prevent and manage risk of bleeding.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 52 555074 Department of Health & Human Services Printed: 09/03/2025 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 555074 B. Wing 03/27/2025

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

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

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

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

F 0658 During a concurrent interview and record review on 3/25/2025 at 11:05 am., reviewed Resident 35's physician's order, subcutaneous administration sites for heparin from 1/8/2025 to 3/25/2025, and the MDS Level of Harm - Minimal harm or with the Minimum Data Set Nurse (MDSN). The MDSN stated Resident 35 received heparin, had a potential for actual harm physician's order for heparin, and were administered as follows:

Residents Affected - Some Heparin 5000 units/ml injection 5000 units:

- 1/20/2025 5:51 a.m. left upper quadrant - LUQ

- 1/20/2025 5:03 p.m. LUQ

- 3/2/2025 6:22 p.m. LUQ

- 3/3/2025 5:14 a.m. LUQ

- 3/7/2024 6:58 a.m. right upper quadrant - RUQ

- 3/7/2025 5:39 a.m. RUQ

- 3/23/2025 5:15 a.m. LUQ

- 3/23/2025 17:32 LUQ

The MDSN stated administration sites for anticoagulants such as heparin should be rotated per standards of practice and manufacture's guideline to prevent hardening or lumps in the skin. The MDSN stated the list of administration sites for the heparin were not rotated. The MDSN stated Resident 35's administration sites should have been rotated to prevent pain, redness, irritation, and lumps on the resident's skin.

During a concurrent interview and record review on 3/27/2025 at 5:00 p.m. with Registered Nurse (RN) 8, RN 8 stated the location of administration sites for Resident 35's heparin were not rotated. RN 8 stated the nurses are supposed to rotate heparin administration sites according to standards of practice, and as indicated in the manufacturer's guideline. RN 8 stated Resident 35's administration sites for heparin should have been rotated to prevent adverse effects such as bruising, skin irritation, skin pits, lipodystrophy and amyloidosis which can affect absorption of the medication.

During a review of the facility-provided manufacturer's guideline for heparin sodium injection solution dated 1/2022, the manufacturer's guideline indicated to use a different site for each injection. The manufacturer's guideline further indicated injection site irritation is one of the most common adverse reactions for the use of heparin.

During a review of the facility's P&P titled, Medication Administration and Monitoring (Sub Acute), last reviewed on 3/2025, the P&P indicated the following:

- Healthcare providers administering medications are responsible for knowing and understanding the dosage, indications, side effects and precautions/warnings of the medications being administered.

- Injection sites for subcutaneous and intramuscular administration must be rotated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 52 555074 Department of Health & Human Services Printed: 09/03/2025 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 555074 B. Wing 03/27/2025

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

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

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

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

F 0658 b. During a review of Resident 42's Face Sheet, the Face Sheet indicated the facility originally admitted the resident on 9/4/2024 and readmitted in the facility on 12/20/2024 with diagnoses including history of stroke Level of Harm - Minimal harm or (loss of blood flow to a part of the brain), tracheostomy (a procedure to help air and oxygen reach the lungs potential for actual harm by creating an opening into the trachea [windpipe] from outside the neck, and ventilator-dependent respiratory failure (condition when a patient's lungs cannot breath on their own and required a machine to Residents Affected - Some help breathe).

During a review of Resident 42's H&P dated 12/22/2024, the H&P indicated Resident 42 was awake and alert but did not indicate the resident's capacity to understand and make decisions.

During a review of Resident 42's MDS, dated [DATE REDACTED], the MDS indicated Resident 42 was able to make his needs known and able to understand others. The MDS further indicated Resident 42 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required substantial/maximal assistance to total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 42 received insulin.

During a review of Resident 42's physician's order, the physician's order dated 2/24/2025 indicated insulin glargine-yfgn (a long-acting insulin) injection vial eight (8) units (a unit of measurement) at bedtime for diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing).

During a review of Resident 42's CP on hyperglycemia last revised on 3/2/2025 with a target date of 7/31/2025, the CP indicated to provide pharmacologic therapy (drug or medication therapy) to maintain blood sugar levels within targeted range.

During a concurrent interview and record review on 3/25/2025 at 11:05 am., reviewed Resident 42's physician's order, subcutaneous administration sites for insulin glargine from 2/24/2025 to 3/25/2025, and

the MDS with the Minimum Data Set Nurse (MDSN). The MDSN stated Resident 42 received heparin, had a physician's order for insulin glargine, and were administered as follows:

Insulin glargine-yfgn injection 8 units:

- 3/12/2024 5:35 p.m. left lower quadrant - LLQ

- 3/13/2025 5:34 p.m. LLQ

- 3/17/2025 5:27 p.m. left upper arm - LUA

- 3/18/2025 5:51 p.m. LUA

The MDSN stated administration sites for insulin should be rotated per standards of practice and manufacture's guideline to prevent hardening or lumps in the skin. The MDSN stated the list of administration sites for Resident 42's insulin glargine were not rotated. The MDSN stated Resident 42's administration sites should have been rotated to prevent pain, redness, irritation, and lumps on the resident's skin.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 52 555074 Department of Health & Human Services Printed: 09/03/2025 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 555074 B. Wing 03/27/2025

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

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

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

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

F 0658 During a concurrent interview and record review on 3/27/2025 at 5:00 p.m. with RN 8, RN 8 stated the location of administration sites for Resident 42's insulin glargine was not rotated. RN 8 stated the nurses are Level of Harm - Minimal harm or supposed to rotate insulin administration sites according to standards of practice, and as indicated in the potential for actual harm manufacturer's guideline. RN 8 stated Resident 42's administration sites for insulin glargine should have been rotated to prevent adverse effects such as bruising, skin irritation, skin pits, lipodystrophy and Residents Affected - Some amyloidosis which can affect absorption of the insulin.

During a review of the facility-provided manufacturer's guideline for insulin glargine (rDNA origin) 100 units/ml three (3) ml pen dated 8/26/2022, the manufacturer's guideline indicated to change (rotate) the injection site for each injection and to inject under the skin of the stomach area, buttocks, upper legs or upper arms.

During a review of the facility's P&P titled, Medication Administration and Monitoring (Sub Acute), last reviewed on 3/2025, the P&P indicated the following:

- Healthcare providers administering medications are responsible for knowing and understanding the dosage, indications, side effects and precautions/warnings of the medications being administered.

- Injection sites for subcutaneous and intramuscular administration must be rotated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 52 555074 Department of Health & Human Services Printed: 09/03/2025 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 555074 B. Wing 03/27/2025

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

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

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 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Minimal harm or potential for actual harm 43988

Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure residents with a urinary catheter (also known as an indwelling catheter, a hollow tube inserted into the bladder to drain or collect urine) received appropriate care and services to prevent urinary tract infections (UTI - an infection in the bladder/urinary tract) for one (1) of 1 sampled resident (Resident 2) reviewed for urinary catheter or UTI by failing to ensure Resident 2's urinary catheter tubing did not have a loop while hanging on the side the bed.

This deficient practice had the potential for the resident's urine not to flow freely which may lead to development of UTI.

Findings:

During a review of Resident 2's Face Sheet, the Face Sheet indicated the facility originally admitted the resident on 6/7/2022 and readmitted in the facility on 1/30/2025 with diagnoses including gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), neurogenic bladder (lack of bladder control due to brain, spinal cord or nerve problems), and tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck).

During a review of Resident 2's History and Physical (H&P), dated 2/2/2025, the H&P indicated Resident 2 was awake and oriented but did not indicate if the resident had the capacity to understand and make decisions.

During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 12/18/2024,

the MDS indicated Resident 2 had intact cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). The MDS further indicated Resident 2 had an indwelling catheter.

During a review of Resident 2's physician's order, dated 1/31/2025, the physician's order indicated:

- Suprapubic catheter (a thin tube inserted directly into the bladder through a small incision in the lower abdomen to drain urine) French (Fr - a unit of measurement) 16 care every shift and as needed. Change every 45 days and as needed for neurogenic bladder.

During an observation, on 3/24/2025, at 9:58 a.m., inside Resident 2's room, Resident 2's urinary drainage bag hung on the left side of the bed with a loop on the tubing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 52 555074 Department of Health & Human Services Printed: 09/03/2025 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 555074 B. Wing 03/27/2025

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

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

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 0690 During a concurrent observation and interview, on 3/24/2025, at 10:10 a.m., inside Resident 2's room with Registered Nurse (RN) 8, RN 8 confirmed and stated Resident 2's urinary drainage bag was hanging on the Level of Harm - Minimal harm or side of the bed and the tubing had a dependent loop. RN 8 stated urinary drainage bags should be potential for actual harm positioned properly so the tubing would not have a dependent loop which prevents the urine from flowing freely into the bag. RN 8 stated Resident 2's indwelling catheter tubing should not have a dependent loop as Residents Affected - Few the urine will not flow freely and can back up into the bladder which may lead to UTI.

During an interview, on 3/27/2025, at 5 p.m., with the Infection Preventionist (IP), the IP stated one of the practices to prevent UTI related to indwelling catheter use is to ensure the urine flow is not obstructed by keeping the tubing free of kinks or loops. The IP stated the staff are supposed to ensure the urinary catheter tubing should not have a loop. The IP stated Resident 2's urinary catheter tubing should have been positioned to prevent loops or kinks to prevent the urine from back up and cause urine infection.

During a review of the facility's policy and procedure (P&P) titled, Urinary Catheter Care (Sub Acute), last reviewed 3/10/2025, the P&P indicated a purpose to provide guidelines for routine care of indwelling and suprapubic urinary catheters and should be followed by all caregivers to reduce the incidence of catheter associated UTI. The P&P further indicated the catheter urinary collection bag is always positioned below the patient's bladder without dependent loops or kinks.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 52 555074 Department of Health & Human Services Printed: 09/03/2025 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 555074 B. Wing 03/27/2025

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

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43988

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure residents receiving enteral feeding (also known as tube feeding, a method of supplying nutrients directly into the gastrointestinal tract) received the appropriate care and services to prevent complications for three of three sampled residents (Resident 2, 35, and 41) reviewed under the tube feeding care area by failing to:

1. Change Resident 35's water flush bag according to the manufacturer's guideline.

2. Indicate the date for Resident 2's medication syringe replacement.

3. Ensure Resident 41 the accurate amount of tube feeding formula was delivered to the resident as ordered.

These deficient practices had the potential to result in altered nutritional status, such as dehydration and malnutrition, and complications associated with enteral feeding, such as gastrointestinal (GI - relating to stomach and intestines) problems, such as abdominal pain and diarrhea, and for residents to experience unmet nutritional needs and place residents at risk for unintended weight loss.

Findings:

a. During a review of Resident 2's Face Sheet (Admission Record), the Face Sheet indicated the facility originally admitted the resident on 6/7/2022 and readmitted in the facility on 1/30/2025 with diagnoses including gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to

the stomach common for people with swallowing problems), neurogenic bladder (lack of bladder control due to brain, spinal cord or nerve problems), and tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck).

During a review of Resident 2's History and Physical (H&P), dated 2/2/2025, the H&P indicated Resident 2 was awake and oriented but did not indicate if the resident had the capacity to understand and make decisions.

During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 12/18/2024,

the MDS indicated Resident 2 had intact cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). The MDS further indicated Resident 2 had a feeding tube (a soft, flexible tube inserted into the stomach or small intestine to deliver nutrition and fluids when someone can't eat or drink normally).

During a review of Resident 2's physician's order, dated 10/28/2024, the physician's order indicated cyclic tube feeding Tube Feeding Formula (TFF - a liquid nutrition delivered directly into the stomach or small intestine via a feeding tube) 4 at 70 milliliter (ml - a unit of measurement for volume) per (/) hour (hr - a unit of measurement for time) start feeding at 5 p.m. until 6 a.m.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 52 555074 Department of Health & Human Services Printed: 09/03/2025 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 555074 B. Wing 03/27/2025

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

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

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 observation, on 3/24/2025, at 9:58 a.m., inside Resident 2's room, Resident 2's medication syringe affixed with a sticker did not indicate a date of when to change the syringe. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview, on 3/24/2025, at 10:10 a.m., inside Resident 2's room, with Registered Nurse (RN) 8, RN 8 stated Resident 2's medication syringe sticker did not indicate the date of Residents Affected - Some when it should be changed. RN 8 stated the medication syringes are supposed to be changed every day and label the sticker with the date it would be changed. RN 8 stated Resident 2's medication syringe should have been labeled with the date it would be changed to ensure the syringe is clean and not contaminated as it placed the resident at risk for acquiring infection from a contaminated medication syringe.

During an interview, on 3/27/2025, at 5 p.m., with the Infection Preventionist (IP), the IP stated medication syringes are changed every day and should indicate in the sticker the date it would be replaced. The IP stated Resident 2's medication syringe should have been labeled with the date it would be replaced as it was

an infection issue and placed the resident at risk for acquiring infection from a contaminated medication syringe.

During a concurrent interview and record review, on 3/26/2025, at 4:30 p.m., with the Nurse Manager (NM),

the facility provided procedure titled, Enteral Tube Feeding, continuous, Gastrostomy, and Jejunostomy, last revised on 11/18/2024, was reviewed and the NM stated the facility follows the procedure for any enteral feeding related issues. The NM stated the procedure did not specifically indicate labeling of the medication syringe. The NM stated per facility practice, medication syringes are supposed to be changed every day and should indicate the date it will be replaced so the staff would know if it was old or new.

b. During a review of Resident 35's Face Sheet, the Face Sheet indicated the facility originally admitted the resident on 11/27/2023 and readmitted in the facility on 7/10/2024 with diagnoses including craniotomy (a type of brain surgery where the surgeon will remove and replace part of the skull to access and treat a problem within the brain), percutaneous endoscopic gastrostomy tube (PEG - a feeding tube inserted directly into the stomach allow a person to receive nutrition through the stomach) dependent, and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body).

During a review of Resident 35's H&P, dated 7/12/2024, the H&P indicated Resident 35 had the presence of tracheostomy.

During a review of Resident 35's MDS, dated [DATE REDACTED], the MDS indicated Resident 35 had severely impaired cognition and required total assistance from staff with all ADLs. The MDS further indicated Resident 35 had a feeding tube.

During a review of Resident 35's physician's order, dated 10/28/2024, the physician's order indicated continuous tube feeding renal Nepro (a therapeutic nutrition designed to meet the nutritional needs of people with kidney disease) at 35 ml/hr.

During an observation, on 3/24/2025, at 11:07 a.m., inside Resident 35's room, Resident 35's water flush bag and label indicated a date of 3/23/2025 at 4 a.m.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 52 555074 Department of Health & Human Services Printed: 09/03/2025 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 555074 B. Wing 03/27/2025

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

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

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 a concurrent observation and interview, on 3/24/2025, at 11:27 a.m., inside Resident 35's room with Licensed Vocational Nurse (LVN) 1, LVN 1 confirmed and stated Resident 35's water flush bag indicated a Level of Harm - Minimal harm or date of 3/23/2025 at 4 a.m. LVN 1 stated water flush bags are changed by the nurse assigned to the resident potential for actual harm as the water flush bags were only good for 24 hours. LVN 1 stated Resident 35's water flush bag had been hanging for more than 24 hours and should have been changed according to the manufacturer's guideline as Residents Affected - Some it can already be contaminated, and Resident 35 can get infection.

During a concurrent observation and interview, on 3/24/2025, at 11:50 a.m., inside Resident 35's room with RN 9, RN 9 stated Resident 35's water flush bag indicated a date and time of 3/23/2025, at 4 a.m., and it had already been more than 24 hours since the bag was last changed. RN 9 stated water flush bags are changed by the nurse assigned to the residents every 24 hours according to the manufacturer's guidelines. RN 9 stated Resident 35's water flush bag should have been changed as it can already be contaminated which placed the resident at risk for acquiring infection.

During an interview, on 3/27/2025, at 5 p.m., with the IP, the IP stated water flush bags are supposed to be changed every 24 hours as indicated in the manufacturer's guideline. The IP stated Resident 35's water flush bag should have been changed as the bag can already be contaminated from being used for more than 24 hours and Resident 35 can get infection from the contaminated water flush bag.

During a review of the facility provide manufacturer's guideline for the Water Flush Bag (WFB) 1, undated,

the manufacturer's guideline indicated the device is intended for enteral feeding only and recommended to be replaced every 24 hours.

During a review of the facility provided procedure titled Enteral Tube Feeding, continuous, Gastrostomy, and Jejunostomy, last revised 11/18/2024, the procedure indicated to change the administration set according to

the manufacturer's instructions to prevent bacterial growth.

38552

c. During a review of Resident 41's Face Sheet, the Face Sheet indicated the facility admitted the resident on 12/11/2024 with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe) and dementia (a progressive state of decline in mental abilities).

During a review of Resident 41's MDS, dated [DATE REDACTED], the MDS indicated the resident had no speech, hearing highly impaired, rarely/never makes self-understood, and rarely/never had the ability to understand others. The MDS indicated the resident had function limitation in range of motion (full movement of a joint) on both sides of upper and lower extremities. The MDS indicated the resident with feeding tube while a resident of the facility.

During a review of Resident 41's physician order, dated 2/26/2025, the physician order indicated TFF 3; 70 ml/hr, continuous 22 hours daily, gastrostomy, free water amount 100 ml, free water frequency every six hours.

During a review of Resident 41's Follow-Up Nutrition Assessment, dated 2/22/2025, the Follow-Up Nutrition Assessment indicated the dietitian recommendations to continue TFF 3 1.2 to 70 milliliters for 22 hours daily to slow down weight loss.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 52 555074 Department of Health & Human Services Printed: 09/03/2025 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 555074 B. Wing 03/27/2025

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

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

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 a review of Resident 41's Flowsheet, dated 3/24/2025 to 3/25/2025, the Flowsheet indicated the following tube feeding intake: Level of Harm - Minimal harm or potential for actual harm - 3/24/2025 at 6 a.m., 794 ml

Residents Affected - Some - 3/24/2025 at 6 p.m., 770 ml

- 3/25/2026 at 6 a.m., 776 ml.

During a review of Resident 41's care plan focusing on enteral nutrition, dated 12/17/2024, the care plan indicated interventions including minimizing unnecessary disruptions to feeding and using enteral nutrition protocol to optimize delivery.

During a concurrent observation and interview, on 3/25/2025, at 8:34 a.m., with RN 9, inside Resident 41's room, the tube feeding connected to Resident 41 indicated TFF 3 labeled with the date 3/25/2025, start time 2 a.m., and set at 70 ml/hr in a one-liter container. RN 9 stated about 750 ml of fluid was left in the TFF 3 container. RN 9 stated 146 ml of formula was administered. RN 9 stated the next shift clears the amount in

the tube feeding machine when they start their shift. RN 9 stated the start date and time was when the new TFF 3 was started, 3/25/2025 at 2 p.m. RN 9 stated the total time from 2 a.m. to 8:30 a.m. is 6 hours and 30 minutes. RN 9 stated when the tube feeding formula rate is set to 70 ml/hr, there should be about 455 ml delivered and should have about 545 ml left in the bag. RN 9 stated they also account for pausing the tube feeding during ADLs or repositioning which takes about 10 to 15 minutes.

During a concurrent interview and record review, on 3/25/2025, at 8:38 a.m., with RN 9, Resident 41's Flowsheet, dated between 3/24/2025 to 3/25/25, nursing notes, dated between 3/24/2025 to 3/25/2025, and physician orders were reviewed. RN 9 stated there was no documentation to account for the 205 ml difference left in the bag. RN 9 stated there should have been a documentation why TFF 3 still had that much formula left in the bag. RN 9 stated there were no new orders to hold Resident 41's tube feeding formula.

During an interview, on 3/27/2025, at 5:42 p.m., with RN 7, RN 7 stated at the start of the primary nurse's shift they check the tube feeding machine regarding the timing, the rate, and clear the amount delivered and monitor how much the resident's intake is. RN 7 stated the primary nurse can set up the machine to deliver

the amount of formula at a set time and once the time has been reached, the machine will alarm. RN 7 stated if there is discrepancy with the amount left in the formula bag the primary nurse should have documented the reason why it has that much left and should have notified the resident's physician and the resident's family about it. RN 7 stated they should have notified the physician because there is no order for bolus or to increase the rate to catch up to the amount the resident is supposed to receive. RN 7 stated they can hold it for a short amount of time when the staff is providing ADLs or repositioning the resident. RN 7 stated the importance of following the order is to ensure the resident receives the amount of nutrients and vitamins as ordered to keep the resident in a healthy condition. RN 7 stated when the set amount of tube feeding formula is not received by Resident 41, the resident could potentially lose weight and may not get enough vitamins, minerals, or calories which can lead to malnutrition.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 52 555074 Department of Health & Human Services Printed: 09/03/2025 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 555074 B. Wing 03/27/2025

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

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

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 a review of the facility's Reference (Ref) 1 titled, Enteral tube feeding, continuous, gastrostomy and jejunostomy, last reviewed and approved on 3/10/2025, the Ref 1 indicated implementation included the Level of Harm - Minimal harm or following: potential for actual harm - Verify the practitioner's order including administration method, volume, rate, and type, volume, and Residents Affected - Some frequency of water flushes.

- Make sure the enteral formula container is labeled with the date and time that the formula was hung, administration route, rate, and duration.

- Frequently monitor the gravity drip rate or enteral feeding pump infusion rate to ensure accurate delivery of

the enteral formula.

During a review of the facility's policy and procedure (P&P) titled, Enteral Feedings, last reviewed and approved on 3/10/2025, the P&P indicated it is the purpose of this policy to provide nourishment to residents who are unable to meet their nutritional needs orally. The P&P indicated enteral formulas/supplements are ordered by the physician or dietitian when directed by the physician. The P&P indicated enteral formula administration and handling guidelines are found in the Ref 1 Procedures for nursing to follow tube feeding administration.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 52 555074 Department of Health & Human Services Printed: 09/03/2025 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 555074 B. Wing 03/27/2025

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

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

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** 43988 potential for actual harm Based on observation, interview and record review, the facility failed to ensure three of five sampled Residents Affected - Some residents (Resident 24, Resident 38, and Resident 40) investigated under the respiratory care area oxygen (type of gas our body needs in order to function) therapy equipment was maintained, and standard infection control practices were followed by failing to ensure:

1. Resident 24 and Resident 38's oxygen tubing did not touch the floor.

2. Resident 40's humidification bottle was labeled and changed per the facility established schedule.

3. Resident 38's Yankauer suction tool (long plastic tool used to remove secretions [thick or thin sticky fluids from the mouth and throat]) was labeled with the date when it was opened.

These deficient practices had the potential for Resident 24, Resident 38, and Resident 40 to develop complications such as infection.

Findings:

1a. During a review of Resident 24's Face Sheet (Admission Record), the Face Sheet indicated the facility originally admitted the resident on 7/16/2020, and readmitted the resident on 3/31/2022, with diagnoses including acute respiratory failure (a condition where the respiratory system is unable to function properly, which can lead to a failure of gas exchange), traumatic brain injury (TBl - a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head), and schizophrenia (a mental illness that is characterized by disturbances in thought).

During a review of Resident 24's History and Physical (H&P), dated 11/11/2024, the H&P indicated the resident is unable to make medical decisions.

During a review of Resident 24's Minimum Data Set (MDS - a resident assessment tool), dated 1/28/2025,

the MDS indicated Resident 24 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). The MDS indicated Resident 24 had tracheostomy (a surgical procedure that creates an opening in the trachea [windpipe] in the front of the neck) and was on continuous oxygen therapy (a treatment that supplies oxygen at higher levels than normal room air).

During a review of Resident 24's physician's orders, dated 12/30/2024, the Order Summary Report indicated

an order of may suction resident for increase secretion three times a day (TID) as needed.

During an observation, on 3/24/2025, at 9:16 a.m., inside Resident 24's room, Resident 24 laid in bed with

the resident's tracheostomy connected to oxygen at two (2) liters per minute (liters/min - a unit of measurement) via tracheostomy mask with the oxygen tubing touching the floor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 52 555074 Department of Health & Human Services Printed: 09/03/2025 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 555074 B. Wing 03/27/2025

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

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

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 a concurrent observation and interview, on 3/24/2025, at 9:40 a.m., with the Infection Preventionist (IP), inside Resident 24's room, the IP confirmed and stated Resident 24's oxygen tubing was touching the Level of Harm - Minimal harm or floor. The IP stated oxygen tubing is not supposed to be touching the floor. The IP stated the tubing is potential for actual harm supposed to be changed to a shorter one if the tubing is too long to prevent the tubing from touching the floor. The IP stated Resident 24's oxygen tubing should not be touching the floor as the floor is dirty and Residents Affected - Some contaminated and can place the resident at risk for acquiring an infection.

During a review of the facility's policy and procedure (P&P) titled, Standards of Care (Sub Acute), last reviewed on 3/10/2025, the P&P indicated the licensed nurse will carry out safety procedures for proper infection control practices, isolation techniques, use of restraints and side rails and care of the environment should be followed as indicated.

1b. During a review of Resident 38's Face Sheet, the Face Sheet indicated the facility admitted Resident 38

on 11/25/2024 with a diagnosis including respiratory failure (lungs are not working well causing difficult breathing).

During a review of Resident 38's, dated 11/26/2024, the H&P indicated Resident 38 had a medical history of tracheostomy, cerebrovascular accident (CVA - stroke, loss of blood flow to a part of the brain), hypertension (HTN - high blood pressure), and urinary bladder (stores urine) neurogenic (brain, spinal cord, and/or nervous system) dysfunction (not working properly).

During a review of Residents 38's MDS, dated [DATE REDACTED], the MDS indicated Resident 38 had severe cognitive impairment and required assistance of two-person physical assist for ADLs. The MDS indicated Resident 38 received oxygen therapy, suctioning, and tracheostomy care.

During a review of Resident 38's Care Plan (CP) titled, Device-Related Complication Risk (Artificial Airway), initiated on 8/29/2024, the CP interventions included: Provide oral (mouth) care regularly, evaluate need for suctioning to minimize risk of airway obstruction (blockage), and apply O2 (oxygen)/ventilation (moving air in and out of lungs).

During a concurrent observation and interview, on 3/24/2025, at 1:45 p.m., with Licensed Vocational Nurse (LVN) 1, in Resident 38's room, the oxygen tubing from Resident 38's tracheostomy site at the neck to the oxygen humidifier (adds moisture to oxygen) on the wall, coiled on the floor. LVN 1 stated the oxygen tubing should not touched the floor because the floor was contaminated (dirty).

During an interview, on 3/27/2025, at 8:38 a.m., with Registered Nurse (RN) 4, RN 4 stated it was important to keep oxygen tubing off the floor for infection control. RN 4 stated we need to prevent tubing from being on

the floor because the resident could get an infection such as ventilator (breathing machine) associated pneumonia ([NAME] - lung infection from using the ventilator through a tube inside the mouth and throat, or through a tracheostomy).

During a review of the facility's P&P titled, Standards of Care - Sub Acute, dated 3/2024, the P&P indicated, Licensed nurse will carry out safety procedures as outlined in the P&P for proper infection control practices, isolation techniques, use of restraints and side rails, and care of the resident's environment should be followed as indicated.

44244

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 52 555074 Department of Health & Human Services Printed: 09/03/2025 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 555074 B. Wing 03/27/2025

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

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

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 2. During a review of Resident 40's H&P, dated 9/27/2024, the H&P indicated the facility originally admitted

the resident on 9/26/2024 with diagnoses including squamous cell carcinoma (a type of cancer) of the neck, Level of Harm - Minimal harm or chronic respiratory failure (serious condition that slowly develops when the lungs cannot get enough oxygen potential for actual harm into the blood) with hypoxia (low oxygen in the tissues), tracheotomy, and ventilator dependence.

Residents Affected - Some During a review of Resident 40's MDS, dated [DATE REDACTED], the MDS indicated the facility originally admitted the resident on 9/26/2024 and most recently admitted on [DATE REDACTED]. The MDS further indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident used a mechanical ventilator and received oxygen therapy.

During a review of Resident 40's Order Report, dated 3/26/2025, the Order Report indicated a physician's order for humidified O2 via T-piece (a device use to help tracheostomy breathing) during waking hours as tolerated with supervision and family on bedside (start at 60 minutes, increase duration daily if possible). Place back on ventilator support if in distress. Titrate (adjust) O2 to maintain 92 percent (%, a measurement), add humidifier, dated 11/15/2024.

During a review of Resident 40's CP on presence of an artificial airway, initiated 9/27/2024, the CP indicated to provide humidification.

During an observation, on 3/24/2025, at 10:30 a.m., inside Resident 40's room, supplemental oxygen via oxygen tubing and a humidifier bottle connected to Resident 40. Resident 40's oxygen humidifier bottle did not indicate the date it was last changed.

During a concurrent observation and interview, on 3/24/2025, at 10:35 a.m., with RN 8, RN 8 entered Resident 40's room, turned on the light, and stated humidification bottles are changed by the night shift and should be labeled with the date the bottle was changed. RN 8 stated Resident 40's humidification bottle was not labeled, and RN 8 did not know when the bottle was last changed.

During a concurrent observation, interview, and record review, on 3/24/2025, at 10:40 a.m., with Respiratory Therapist (RT) 1, the Subacute Supply Change and Equipment Check Schedule was reviewed. RT 1 confirmed and stated oxygen humidification bottles are changed every three days and the bottles are labeled with the date the bottle was last changed. RT 1 assessed Resident 40's oxygen humidification bottle and stated the bottle did not indicate the date it was last changed. RT 1 stated there was no documentation indicating Resident 40's humification bottle was changed within the last three days. RT 1 stated if Resident 40's humidification bottle was not labeled with the date, then RT 1 did not know when the bottle was last changed.

During an interview, on 3/27/2025, at 8:35 a.m., with the Nurse Manager (NM), the NM stated oxygen humidification bottles are changed every three days and must be labeled with the date last changed. The NM stated it was important to label with the date to communicate when the bottles were last changed and to identify when the bottle needs to be changed next. The NM stated when Resident 40's oxygen humidification bottle did not indicate the date it was last changed, there was a risk the bottle was used for an extended amount of time causing an infection control issue. The NM stated Resident 40 is connected to a ventilator system and when the humidification bottle was not changed, there was a potential for the resident to develop

a respiratory infection. The NM stated the facility policy and procedures regarding infection control were not followed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 52 555074 Department of Health & Human Services Printed: 09/03/2025 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 555074 B. Wing 03/27/2025

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

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

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 a review of the facility provided, Subacute Supply Change and Equipment Check Schedule, last reviewed 4/2024, the Subacute Supply Change and Equipment Check Schedule indicated the RT is Level of Harm - Minimal harm or responsible for ventilator patients. The bubble humidifier (humidification bottle) is changed by the day shift potential for actual harm when the water level is 25 % or every three days.

Residents Affected - Some During a review of the facility's policy and procedure (P&P) titled, Standard Precautions and Transmission-Based Precautions, last reviewed 3/10/2025, the P&P indicated standard precautions is the primary practice used for the prevention of the spread of disease and infections. Standard precautions are used in the care of all patients regardless of their diagnosis or presumed infection status. All caregivers including clinical and non-clinical caregivers are expected to follow appropriate precautions. Ensure single use items are discarded properly.

50516

3. During a concurrent observation and interview on 3/24/2025 at 1:45 p.m., with LVN 1, in Resident 38's room, Resident 38's Yankauer suction tool was opened and had yellow secretions inside. LVN 1 stated the Yankauer did not have a date of when it was opened or needed to be changed. LVN 1 stated I don't know when it was opened. LVN 1 stated the Yankauer should be changed every day and as needed and should be dated when it was opened or needed to be changed.

During an interview on 3/27/2025 at 8:38 a.m., with Registered Nurse (RN) 4, RN 4 stated if oxygen equipment was not changed on the right date or time, it could cause an infection for the resident.

During a review of the facility's policy and procedure (P&P) titled, Standards of Care - Sub Acute, dated 3/2024, the P&P indicated, licensed nurse will carry out safety procedures as outlined in the P&P for proper infection control practices, isolation techniques, use of restraints and side rails, and care of the resident's environment should be followed as indicated.

During a review of the facility's procedure titled Subacute (more specialized care than a general skilled nursing facility) Supply Change and Equipment Check Schedule, undated, the procedure indicated to change

the Yankauer weekly and PRN (as needed) when soiled (caking [dried or hardened substance] present).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 52 555074 Department of Health & Human Services Printed: 09/03/2025 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 555074 B. Wing 03/27/2025

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

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs.

Level of Harm - Minimal harm or 38552 potential for actual harm Based on interview and record review, the facility failed to specify an indication (the reason) for the use of a Residents Affected - Few hypoglycemic medication (lowers blood sugar) for one of five sampled residents (Resident 41) during a

review of unnecessary medications when insulin (a hormone that removes excess sugar from the blood) lispro (fast-acting insulin) did not have an indication.

This deficient practice had the potential to result in not medically necessary treatments potentially leading to ineffective diabetes management.

Findings:

During a review of Resident 41's Face Sheet, the Face Sheet indicated the facility admitted the resident on 12/11/2024 with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).

During a review of Resident 41's Minimum Data Set (MDS-a resident assessment tool), dated 2/25/2025, the MDS indicated the resident had no speech, hearing was highly impaired, rarely/never made self understood, and rarely/never understood The MDS indicated the resident was taking medications in high-risk drug classes which includes hypoglycemics.

During a concurrent interview and record review on 3/25/2025 at 3:50 p.m. with Registered Nurse (RN) 2, Resident 41's physician orders were reviewed. RN 2 stated Resident 41 received the following insulins:

- Glargine (long-acting insulin) 100 unit per milliliter (ml-a unit of measurement), 25 units (0.25 ml) subcutaneous (SQ- situated or applied under the skin) for diabetes, routine, order dated 12/22/2024.

- Lispro 0-12 units, SQ, two times daily, order dated 12/11/2024. RN 2 stated there was no indication noted

on the use of Lispro.

During an interview on 3/27/2025 at 5:35 p.m., with RN 7, RN 7 stated medication order components would need to have the medication name, dose, route, timing, blood sugar levels, and diagnosis. RN 7 stated the purpose of the diagnosis is to know what it is they are giving it for and if the primary nurse is not familiar about the medication they should ask and clarify with the physician what they are giving it for. RN 7 stated

this is part of the medication rights.

During a review of the facility's policy and procedure (P&P) titled, Medication Administration and Monitoring (Sub Acute), last revised and approved on 3/10/2025, the P&P indicated before administering the medication, the eMAR is reviewed and to always observe the seven-rights of medication administration: the right drug, the right patient, the right time, the right dose of the drug, the right route, the right reason (indication), and the right documentation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 52 555074 Department of Health & Human Services Printed: 09/03/2025 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 555074 B. Wing 03/27/2025

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

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

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

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

F 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43988 potential for actual harm Based on interview and record review, the facility failed to ensure residents are free of any significant Residents Affected - Some medication errors for two of two sampled residents (Residents 35 and 42) reviewed for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) and anticoagulant (a substance that is used to prevent and treat blood clots in blood vessels and the heart) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin and heparin (an anticoagulant) administration sites.

The deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin and anticoagulants (a substance that is used to prevent and treat blood clots in blood vessels and the heart) such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a rare disease that occurs when a protein called amyloid builds up in organs).

Cross Reference

F-F835

Findings:

During a review of Resident 3's Face Sheet, the Face Sheet indicated the facility readmitted the resident on 2/17/2025 with diagnoses including acute hypoxic respirator (a condition where the lungs cannot get enough oxygen into the blood) and hyperlipidemia (abnormally high fat).

During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool), dated 2/5/2025, the MDS indicated the resident's initial start date at the facility on 10/29/2024. The MDS indicated the resident had adequate hearing and unclear speech. The MDS indicated the resident made self understood and sometimes understood others. The MDS indicated the resident was dependent on staff with toileting, oral hygiene, shower/bathing self, lower body dressing, and personal hygiene. The MDS indicated the resident was taking antibiotics.

During a review of Resident 3's physician order, dated 3/4/2025, the physician order indicated levofloxacin (Levaquin) tablet 500 milligrams (mg-a unit of measurement) per gastrostomy tube (g-tube- a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) for UTI, daily, end date 3/10/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 52 555074 Department of Health & Human Services Printed: 09/03/2025 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 555074 B. Wing 03/27/2025

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

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

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 0881 During a concurrent interview and review on 3/27/2025 at 10:41 a.m. with the Infection Preventionist (IP), Resident 3's physician order, nursing progress notes, and registered nurses' plan of care, antibiotic tracking Level of Harm - Minimal harm or sheet (a document or tool used to monitor and record prescribed antibiotics and usage patterns [how often, potential for actual harm how much, and what reason it's prescribed]), and Loeb's minimum criteria (evidence-based national standard criteria for initiating antibiotic treatment designed to reduce inappropriate prescribing by outlining minimum Residents Affected - Few clinical signs and symptoms suggesting an infection) for initiating antibiotic therapy were reviewed. The Plan of Care indicated, on 3/1/2025 at 11:25 a.m., Resident 3 was noted with increased heart rate and had a temperature of 101.1 degrees Fahrenheit (F - a unit of measurement). The IP stated she uses the antibiotic tracking sheet and the Loeb's minimum criteria for initiating antibiotic therapy as a guide to monitor and

review new or changes in antibiotic orders and uses Loeb's criteria, but this is not indicated in their policy.

The IP stated they do not have a standard protocol in using the Loeb's criteria that shows which residents have met or have not met the criteria. The IP stated when Loeb's criteria is used for Resident 3's use of levofloxacin for UTI without urinary catheter, the resident would not have met the criteria because the resident only have increased heart and fever as signs and symptoms of infection. The IP stated the Loeb's minimum criteria for UTI includes either one of the following criteria: acute dysuria (discomfort or pain when urinating) or temperature greater than 100 F, and one or more of the following new or worsening symptoms: urgency, suprapubic pain (pain above pelvic bone), urinary incontinence, frequency, gross hematuria (visible blood in the urine), and costovertebral angle tenderness (pain in the upper back near the ribs).

During a concurrent interview and record review on 3/27/2025 at 10:50 a.m. with the IP, the facility's policy and procedure (P&P) titled, Antimicrobial Stewardship (AMS) Program, last reviewed and approved on 3/10/2025, was reviewed. The IP stated the P&P did not indicate the protocol on the use of antibiotic tracking sheet and the use of Loeb's criteria to assess the residents for any infection. The IP stated she should have mentioned to the Manager of Infection Prevention (MIP) about the use of antibiotic tracking sheet and the use of Loeb's minimum criteria in initiating antibiotic therapy when they reviewed their P&Ps.

During an interview on 3/27/2025 at 1:57 p.m. with the IP, the IP stated when the resident does not meet the Loeb's minimum criteria, she would notify the resident's physician that the resident did not meet the criteria to initiate the antibiotic then document on the resident's chart what she did and what the physician's response was.

During a concurrent interview and record review on 3/27/2025 at 2:12 p.m. with Registered Nurse (RN) 2, Resident 3's nursing progress notes, plan of care, and physician orders were reviewed. RN 2 stated he was covering for the IP when Resident 3 had the order for levofloxacin for UTI. RN 2 stated he notified the primary nurse about the resident's laboratory results that were ordered, and he (RN 2) does not use any standardized criteria when reviewing antibiotics.

During an interview on 3/27/2025 at 3:17 p.m. with the MIP, the MIP stated she was not aware of the Centers of Medicare and Medicaid Services (CMS- a federal agency that administers major healthcare programs) of

the regulation antibiotic stewardship regulation requirements to be implemented. The MIP stated they have

an ASP which they collaborate with the antimicrobial stewardship pharmacist. The MIP stated the purpose of

the ASP is to administer antibiotics in the least amount of duration, and to make sure the antibiotic ordered had the appropriate frequency and dose to prevent multidrug resistance organisms.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 52 555074 Department of Health & Human Services Printed: 09/03/2025 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 555074 B. Wing 03/27/2025

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

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

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 0881 During a review of the facility's P&P titled, Antimicrobial Stewardship (AMS) Program, last reviewed and approved on 3/10/2025, the P&P indicated it is the facility's policy to implement a comprehensive AMS Level of Harm - Minimal harm or program to evaluate judicious use of antimicrobials. The P&P indicated the purpose of the P&P is to optimize potential for actual harm antibiotic therapy to improve clinical outcomes while minimizing unintended consequences of antimicrobial use, such as drug toxicity (drug causing harm) and emergence of resistance. Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 52 555074 Department of Health & Human Services Printed: 09/03/2025 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 555074 B. Wing 03/27/2025

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

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38552 potential for actual harm Based on interview and record review, the facility failed to document that pneumococcal vaccine was offered Residents Affected - Few for the resident and education was provided to the family/decision-maker per its pneumococcal vaccine (an injected medicine that can protect against and often prevent pneumococcal [a type of bacteria] infections [when the immune system fights off the bad germs to get better]) policy and procedures (P&P) for one of five sampled residents (Resident 19) reviewed for immunizations under Infection Control facility task.

This deficient practice had the potential to result in increased risk for pneumococcal infections which may lead to serious health complications such as pneumonia (an infection that inflames the lungs' air sacs), meningitis (inflammation of brain and spinal cord membranes, typically caused by an infection), and bloodstream infections.

Findings:

During a review of Resident 19's Face Sheet, the Face Sheet indicated the resident was admitted on [DATE REDACTED] with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe on your own) and seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness).

During a review of Resident 19's Minimum Data Set (MDS- a resident assessment tool), dated 1/30/2025,

the MDS indicated the resident rarely/never made self understood and rarely/never understood others.

During a concurrent interview and record review on 3/27/2025 at 9:37 a.m. with the Infection Preventionist (IP), Resident 19's Immunization Summary, plan of care, and nursing progress notes were reviewed. The IP stated there was no documentation that pneumococcal vaccine was offered for the resident, and that education was provided to the resident's family/decision-maker. The IP stated Registered Nurse (RN) 2 was covering for her during the time they were reviewing residents eligible to receive pneumococcal vaccines.

During a concurrent interview and record review on 3/27/2025 at 2:12 p.m. with RN 2, Resident 19's plan of care and nursing progress notes were reviewed. RN 2 stated he missed documenting the discussion he had with Resident 19's family member where she (Resident 19's family member) consented for the resident to receive the pneumonia vaccine. RN 2 stated he was supposed to document and enter the order on the same day after the discussion with the family member.

During an interview on 3/27/2025 at 5:57 p.m. with RN 7, RN 7 stated the purpose for offering and providing education of pneumococcal vaccine is for prevention especially many residents in their facility are at a higher risk of contracting pneumonia.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 52 555074 Department of Health & Human Services Printed: 09/03/2025 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 555074 B. Wing 03/27/2025

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

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

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 0883 During a review of the facility's P&P titled, Vaccines (Influenza and Pneumococcal) - (Sub Acute), last reviewed and approved on 3/10/2025, the P&P indicated it is the facility's policy to reduce potential for Level of Harm - Minimal harm or transmitting and/or contracting influenza and/or pneumonia among Sub-Acute (for residents needing potential for actual harm services that are more intensive than those typically received in long-term care but less intensive than acute care) residents. The P&P indicated before offering the pneumococcal immunization, each resident or the Residents Affected - Few resident's legal representative receives education regarding the benefits and potential side effects of the immunization; offer each resident a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized; indicate in the resident's medical record, includes documentation indicating, minimum, of the following: provide resident or resident's legal representative education regarding benefits and potential side effects of pneumococcal immunization.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 52 555074

F-F881

Findings:

During a review of Resident 3's Face Sheet, the Face Sheet indicated the facility admitted the resident on 2/17/2025 with diagnoses including acute hypoxic respirator (a condition where the lungs cannot get enough oxygen into the blood) and hyperlipidemia (abnormally high fat).

During a review of Resident 3's MDS, dated [DATE REDACTED], the MDS indicated the resident's initial start date at the facility on 10/29/2024. The MDS indicated the resident had adequate hearing and unclear speech. The MDS indicated the resident made self understood and sometimes understood others. The MDS indicated the resident was dependent on staff with toileting, oral hygiene, shower/bathing self, lower body dressing, and personal hygiene. The MDS indicated the resident was taking antibiotics.

During a review of Resident 3's physician order, dated 3/4/2025, the physician order indicated levofloxacin (Levaquin) tablet 500 milligrams (mg-a unit of measurement) per gastrostomy tube (g-tube- a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) for UTI, daily, end date 3/10/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 52 555074 Department of Health & Human Services Printed: 09/03/2025 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 555074 B. Wing 03/27/2025

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

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

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 0835 During a concurrent interview and review on 3/27/2025 at 10:41 a.m. with the Infection Preventionist (IP), Resident 3's physician order, nursing progress notes, and registered nurses' plan of care, antibiotic tracking Level of Harm - Minimal harm or sheet (a document or tool used to monitor and record prescribed antibiotics and usage patterns [how often, potential for actual harm how much, and what reason it's prescribed]), and Loeb's minimum criteria (evidence-based national standard criteria for initiating antibiotic treatment designed to reduce inappropriate prescribing by outlining minimum Residents Affected - Many clinical signs and symptoms suggesting an infection) for initiating antibiotic therapy were reviewed. The Plan of Care indicated, on 3/1/2025 at 11:25 a.m., Resident 3 was noted with increased heart rate and had a temperature of 101.1 degrees Fahrenheit (F - a unit of measurement). The IP stated she uses the antibiotic tracking sheet and the Loeb's minimum criteria for initiating antibiotic therapy as a guide that she uses to monitor and review new or changes in antibiotic orders and uses Loeb's criteria, but this is not indicated in their policy. The IP stated they do not have a standard protocol in using the Loeb's criteria that shows which residents have met or have not met the criteria. The IP stated when Loeb's criteria is used for Resident 3's use of levofloxacin for UTI without urinary catheter, the resident would not have met the criteria because the resident only have increased heart and fever as signs and symptoms of infection. The IP stated the Loeb's minimum criteria for UTI includes either one of the following criteria: acute dysuria (discomfort or pain when urinating) or temperature greater than 100 F, and one or more of the following new or worsening symptoms: urgency, suprapubic pain (pain above pelvic bone), urinary incontinence, frequency, gross hematuria (visible blood in the urine), and costovertebral angle tenderness (pain in the upper back near the ribs).

During a concurrent interview and record review on 3/27/2025 at 10:50 a.m. with the IP, the facility's P&P titled, Antimicrobial Stewardship (AMS) Program, last reviewed and approved on 3/10/2025, was reviewed.

The IP stated the P&P did not indicate the protocol on the use of antibiotic tracking sheet and the use of Loeb's criteria to assess the residents for any infection. The IP stated she should have mentioned to the Manager of Infection Prevention (MIP) about the use of antibiotic tracking sheet and the use of Loeb's minimum criteria in initiating antibiotic therapy when they reviewed their P&Ps.

During an interview on 3/27/2025 at 1:57 p.m. with the IP, the IP stated when the resident does not meet the Loeb's minimum criteria, she would notify the resident's physician that the resident did not meet the criteria to initiate the antibiotic then document on the resident's chart what she did and what the physician's response was.

During a concurrent interview and record review on 3/27/2025 at 2:12 p.m. with Registered Nurse (RN) 2, Resident 3's nursing progress notes, plan of care, and physician orders were reviewed. RN 2 stated he was covering for the IP when Resident 3 had the order for levofloxacin for UTI. RN 2 stated he notified the primary nurse about the resident's laboratory results that were ordered, and he (RN 2) does not use any standardized criteria when reviewing antibiotics.

During an interview on 3/27/2025 at 3:17 p.m. with the MIP, the MIP stated she was not aware of the Centers of Medicare and Medicaid Services (CMS- a federal agency that administers major healthcare programs) of

the regulation antibiotic stewardship regulation requirements to be implemented. The MIP stated they have

an ASP which they collaborate with the antimicrobial stewardship pharmacist. The MIP stated they purpose of the ASP is to administer antibiotics in the least amount of duration, and to make sure the antibiotic ordered had the appropriate frequency and dose to prevent multidrug resistance organisms.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 52 555074 Department of Health & Human Services Printed: 09/03/2025 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 555074 B. Wing 03/27/2025

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

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

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 0835 During a review of the facility's P&P titled, Antimicrobial Stewardship (AMS) Program, last reviewed and approved on 3/10/2025, the P&P indicated it is the facility's policy to implement a comprehensive AMS Level of Harm - Minimal harm or program to evaluate judicious use of antimicrobials. The P&P indicated the purpose of the P&P is to optimize potential for actual harm antibiotic therapy to improve clinical outcomes while minimizing unintended consequences of antimicrobial use, such as drug toxicity (drug causing harm) and emergence of resistance. Residents Affected - Many

During a review of the facility P&P titled, Department Policy Guidelines, last reviewed and approved on 3/10/2025, the P&P indicated the policy's purpose was to provide guidelines for the creation and/or review of policies, and to outline the approval process. Departmental policies and procedures are created, approved, maintained and archived in a consistent and timely manner, following a standardized approval and maintenance process. The ''Policy Owner is the Director/Manager of each department, as they are responsible for the creation, review, revision, removal, and/or archive of their department's policies. The Policy Owner is responsible for updating policy. All clinical content is to be reviewed and revised by licensed caregivers and/or department Directors/Managers. Ensure policy content and formatting accuracy. Check that policy content is correct and applies to the department/unit's current practices. Ensure the policy is within scope of practice, and in accordance with Nurse Practice Act. Confirm that the policy contains the most current and evidence-based information. All departments are required to review their departmental policies according to the following timelines, and as needed for regulatory purposes. It is the responsibility of

the department manager to ensure that appropriate documentation is maintained for any Standardized Procedures used in their department/area.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 52 555074 Department of Health & Human Services Printed: 09/03/2025 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 555074 B. Wing 03/27/2025

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

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

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** 44244 potential for actual harm Based on observation, interview, and record review the facility failed to implement and maintain an infection Residents Affected - Some control program by failing to ensure Registered Nurse (RN) 9, accompanied by the Nurse Practitioner (NP) and Medical Doctor (MD), implemented Contact Precautions (an infection control measure aimed to prevent spread of infection by direct or indirect contact by the use of personal protective equipment [PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments]) during rounding in the residents room for one of five sampled residents (Resident 39) reviewed under the Infection Control task area.

This deficient practice had the potential to result in the spread of infectious microorganisms amongst staff, residents, and visitors.

Findings:

During a review of Resident 39's History and Physical (H&P), dated 3/27/2025, the H&P indicated the resident was readmitted to the facility on [DATE REDACTED] with diagnoses that included prostate (a gland in the male reproductive system) cancer, chronic respiratory failure (serious condition that slowly develops when the lungs cannot get enough oxygen into the blood) with tracheostomy (opening surgically created through the front of the neck and into the trachea [windpipe]), and percutaneous endoscopic gastrostomy (PEG or GT - a tube placed directly into the stomach to give direct access for supplemental feeding, hydration or medicine) placement.

During a review of Resident 39's Minimum Data Set (MDS - a resident assessment tool), dated 1/24/2025,

the MDS indicated the resident was originally admitted to the facility on [DATE REDACTED]. The MDS further indicated

the resident sometimes had the ability to make self-understood and sometimes understood others. The MDS indicated the resident was dependent on staff for oral and personal hygiene, bathing, dressing, toileting, and mobility.

During a review of Resident 39's Physician Orders, dated 11/18/2024, the Physician Orders indicated a physician's order for contact isolation for Carbapenem-resistant pseudomonas aeruginosa (CRPA - an infectious bacteria spread through contact with contaminated surfaces, healthcare workers, or equipment); multidrug-resistant pseudomonas aeruginosa (MDRA - infectious bacteria that are resistant to the effects of multiple types of antibiotics [medication used to treat bacteria])

During an observation, on 3/24/2025, at 10:55 a.m., Resident 39's entry to the room had a contact isolation sign posted. The sign indicated before entering the room, all staff and visitors must put on a gown and gloves. RN 9, Resident 39's NP and MD were inside Resident 39's room not wearing gowns. RN 9, the NP, and the MD exited the resident's room after speaking with Resident 39's family member.

During an interview, on 3/24/2025, at 11 a.m., with RN 9 upon exiting Resident 39's room, RN 9 stated Resident 39 had a contact isolation sign at the entry to the room because the resident was on contact isolation. RN 9 stated gloves and a gown should be donned (put on) before entering the resident's room. RN 9 stated that RN 9, the NP, and the MD did not don gowns prior to entering or while inside the resident's room because they were not touching the resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 52 555074 Department of Health & Human Services Printed: 09/03/2025 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 555074 B. Wing 03/27/2025

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

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

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

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

F 0880 During an interview, on 3/27/2025, at 11:44 a.m., with the facility Infection Preventionist (IP), the IP stated Resident 39 was diagnosed with CRPA. The IP stated CRPA can be spread amongst staff, residents, and Level of Harm - Minimal harm or visitors by touching surfaces contaminated with secretions or when secretions unexpectedly exit a resident's potential for actual harm mouth or tracheostomy tubing during a cough. The IP stated to prevent the spread of CRPA, anyone entering the resident's room must don a disposable gown to prevent contamination of the staff or visitor's Residents Affected - Some clothing. The IP stated staff and visitors should don a gown even if they do not intend to touch the resident or any environmental surfaces. The IP stated the gown prevents any cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) from Resident 39 to any of the other residents that the NP, MD, or RN 7 visit during their rounds.

During an interview, on 3/27/2025, at 8:35 a.m., with the Nurse Manager (NM), the NM stated facility residents are at increased risk of infection and wearing a gown prevents the spread of infection between residents. The NM stated when RN 9, the NP, and the MD did not don gowns while inside Resident 39's room, the facility policy and procedures regarding contact isolation were not followed.

During a review of the facility's policy and procedure (P&P) titled, Standard Precautions and Transmission-Based Precautions, last reviewed 3/10/2025, the P&P indicated standard precautions are the primary practice used for the prevention of the spread of disease and infections. Standard precautions are used in the care of all residents regardless of their diagnosis or presumed infection status. All caregivers including clinical and non-clinical caregivers are expected to follow appropriate precautions. Contact precautions are used in addition to standard precautions. Use contact precautions for residents known or suspected to be infected or colonized with epidemiologically important / significant microorganisms that can be transmitted, by direct / indirect contact. For the resident who appears to have a disease requiring contact precautions, it is important to institute the appropriate precautions immediately. The appropriate sign should be posted on the resident's door. In addition to standard precautions, wear a gown providing 360-degree coverage to protect skin and prevent soiling and / or contamination of clothing. [NAME] PPE when entering a resident's room based on the anticipated interaction with the resident and environment. Remove / doff PPE

before leaving the resident's room.

During a review of the facility's P&P titled, [Regional] Standard Precautions and Transmission-Based Precautions, Appendix A last reviewed 3/10/2025, the P&P indicated contact precautions are recommended

in long term care facilities for carbapenem resistant organisms.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 52 555074 Department of Health & Human Services Printed: 09/03/2025 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 555074 B. Wing 03/27/2025

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

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

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 0881 Implement a program that monitors antibiotic use.

Level of Harm - Minimal harm or 38552 potential for actual harm Based on interview and record review, the facility failed to fully develop and implement an antibiotic Residents Affected - Few (antimicrobial, medicine that inhibits the growth of or destroys microorganisms) stewardship program (ASP- a coordinated program that promotes the appropriate use of drugs used to treat infections, including antibiotics as a part of its overall Infection Prevention and Control Program (IPCP) for one of six sampled residents (Resident 3) reviewed under Infection Control facility task by:

1. Failing to establish protocols to identify signs and symptoms of infections among residents to assess whether they met evidence-based national standard criteria for initiating antibiotic treatment

2. Failing to identify Resident 3's use of levofloxacin (antibiotic) indicated for urinary tract infection (UTI- an infection in the bladder/urinary tract).

These deficient practices had the potential to result in increased risk of inappropriate antibiotic use, potentially leading to adverse outcomes (complications arising from an intervention or condition) such as antibiotic resistance (the acquired ability of bacterial pathogens to withstand the effects of antimicrobial agents, reducing treatment efficacy).

Cross Reference