Health Inspection

Cottage Crest Post Acute

Inspection Date: June 11, 2024

Total Violations 2

Facility ID 055758

Location NORWALK, CA

Inspection Findings

F-Tag F755

Harm Level: Minimal harm or

Residents Affected: Many Based on observation and interview, the facility failed to ensure safe and sanitary food storage and food

F-F755)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 74 055758 Department of Health & Human Services Printed: 09/23/2025 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 055758 B. Wing 06/11/2024

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

Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

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** 46415

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

1. Failing to dispose expired food from the fridge.

2. Failed to store food in the appropriate section.

3. Failed to do proper hygiene when entering the kitchen.

These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea and fever and can lead to other serious medical complications and hospitalization .

During a concurrent observation of the refrigerator and interview on [DATE REDACTED] at 8:26a.m. with Dietary Aide 1 (DA 1). DA 1 stated the cilantro in the bag that was dated [DATE REDACTED] is supposed to be good for one week and was supposed to be thrown away. It was noted the cilantro was changing color and was turning yellow. It was additionally observed there was an avocado, ginger, yellow pepper, and one lemon in the bin with no date.

During a concurrent observation of freezer two (2) and interview on [DATE REDACTED] at 8:36a.m. with DA 1, on the bottom of the shelf, there was a box of bacon dated [DATE REDACTED], a box of frozen blackberries behind the box of bacon, cookie dough, pizza crust, and pastries. DA 1 stated the bacon and blackberries are not supposed to be there.

During a concurrent observation and interview on [DATE REDACTED] at 8:42a.m. with Dietary Manager (DM) in the dry pantry, there was a Tabasco sauce (a brand of hot sauce) with an expiration date of ,d+[DATE REDACTED] and DM stated it was supposed to be tossed out.

During a concurrent observation and interview on [DATE REDACTED] at 8:48a.m. with DM in the dry pantry, there was almond extract with an expiration date of ,d+[DATE REDACTED].

During a concurrent observation and interview on [DATE REDACTED] at 8:50a.m. with DM in the dry pantry, there was a box of three melons and a few bananas that was browning with no dates. DM stated there are no expiration dates for fruits and it will be thrown away when it goes bad or starts smelling. DM was observed throwing out

the bananas because they were brown, soft, and mushy.

During a concurrent observation and interview on [DATE REDACTED] at 8:52a.m. with DM in the dry pantry, there were six unopened instant coffee grounds in the bag with an expiration date of [DATE REDACTED]. DM stated they no longer use the instant coffee grounds.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 74 055758 Department of Health & Human Services Printed: 09/23/2025 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 055758 B. Wing 06/11/2024

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

Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

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

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

F 0812 During a concurrent observation and interview on [DATE REDACTED] at 9:02a.m. with DM, DM stated they check the freshness daily for cilantro. DM stated the cilantro dated [DATE REDACTED] and was bad and had to be thrown out since Level of Harm - Minimal harm or it was yellowing. potential for actual harm

During a concurrent observation and interview on [DATE REDACTED] at 9:05a.m. with DM, DM stated the parsley dated Residents Affected - Many [DATE REDACTED] with no expiration date is still fresh because there were no issues with the parsley leaves in the bag. DM observed the celery that was a little brown at the top that was in a clear container with no covering dated [DATE REDACTED] with no expiration date and the DM stated she does not know when the celery came in.

During a concurrent observation of freezer two (2) and interview on [DATE REDACTED] at 12:31p.m. with DM, DM stated

the apple bacon box on top of the cookie dough box was acceptable to be stored on the same shelf because

the bacon and cookie dough was sealed.

During a concurrent observation of the refrigerator and interview on [DATE REDACTED] at 12:34p.m. with DM, it was observed there was a bag of sausages on the same shelf as fruits with cured meat stored on the bottom shelf. DM stated the bag of sausages are supposed to be at the bottom with the cured meat, because it is raw, and all meats should be at the bottom. DM stated if the bag was open, it can cause cross contamination, but since it is sealed, she stated she does not mind if the meat is touching other items.

During a concurrent observation, interview, and record review of the refrigerated storage quick reference guide on [DATE REDACTED] at 12:37p.m. with DM, DM reiterated the celery in the container dated [DATE REDACTED] was mislabeled and the celery in the refrigerator was delivered not too long ago. DM stated according to the refrigerated storage quick reference guide, celery that is unopened is stored for one week with no applicable storage time for opened celery. Additionally, the handling hints indicated to keep in crisper or moister resistant wrap or bag and DM stated the celery was supposed to be covered in a bag. DM concurred that the celery that was observed together was not covered, it was in the box, and it was more than a week. Parsley and cilantro were also received and indicated it should be kept for one week and was noted both of them were expired. DM stated expired items are tossed out as it can make people sick, and it has passed its shelf life. DM stated labeling is important to keep the items fresh and prevent the item from expiring.

During an observation on [DATE REDACTED] at 10:39a.m., Dietary Aide 2 (DA 2) that was stationed at the dishwasher station was observed removing her gloves and left the kitchen without performing hand hygiene.

During an observation on [DATE REDACTED] at 10:30a.m. DA 2 was observed coming back into the kitchen, proceeded to wear gloves, and went to the dishwashing section and started cleaning the trays. No hand hygiene was observed from the moment DA 2 entered the kitchen.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 74 055758 Department of Health & Human Services Printed: 09/23/2025 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 055758 B. Wing 06/11/2024

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

Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

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

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

F 0812 During a concurrent observation and interview on [DATE REDACTED] at 10:47a.m. with DA 1, DA 1 was observed removing the lid off the blender and placed the mix into a container. DA 1 with the same glove reaches into Level of Harm - Minimal harm or the sanitation red bucket and removes a towel, cleaned the counter, the blender machine, laid out the towel potential for actual harm in the sink, rinsed the towel and proceeded to put the towel back into the sanitation box. DA 1 was observed removing her gloves and placed them in the sink. DA 1 continued to get foil, placed it on mix contained that Residents Affected - Many contained the beef and broccoli puree, put on the oven mittens, and placed the mix in the oven. DA 1 stated

she is not supposed to use the same glove and get into the sanitation bucket as it would get dirty. DA 1 stated hand washing is performed to prevent the spread of bacteria and for infection control.

During an interview on [DATE REDACTED] at 11:00a.m. with DA 2, DA 2 stated she normally washed her hand at the sink located across the kitchen and stated she washed her hand upon returning to the kitchen earlier. DA 2 stated she was supposed to wash hands after leaving/coming back into the kitchen. DA 2 stated it is not acceptable to not washing hands and touch dirty to clean areas with the same gloves. DA 2 stated hand hygiene should be performed because your hands are dirty and can spread bacteria.

During a review of the facility's P&P titled, Food Storage, revised [DATE REDACTED], the P&P indicated improper storage of food is the main reason for food borne illness. All food stored should be dated when it is placed in

the storeroom, refrigerator or freezer.

During a review of the facility's P&P titled, Food Storage, revised [DATE REDACTED], the P&P indicated any expired or outdated food products should be discarded. Fresh vegetables should be checked and sorted for ripeness. Vegetables should be left in cartons, bags, or paper wrapping because it retards spoilage and loss of moisture.

During a review of the facility's P&P titled, Handwashing and Glove Use, revised [DATE REDACTED], the P&P indicated handwashing is a priority for infection control. Hands must be washed prior to beginning work .and following contact with any unsanitary surface i.e. touching hair, sneezing, opening doors, etc. When gloves are used, handwashing must occur per above procedure prior to putting on gloves and whenever gloves are changed. Gloves must be changed as often as hands need to be washed, see above .gloves may be used for one task only.

During a review of the facility's P&P titled, Receiving Food and Supplies, revised [DATE REDACTED], the P&P indicated all foodstuffs are to be dated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 74 055758 Department of Health & Human Services Printed: 09/23/2025 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 055758 B. Wing 06/11/2024

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

Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

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

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

F 0814 Dispose of garbage and refuse properly.

Level of Harm - Minimal harm or 46415 potential for actual harm Based on observation and interview, the facility failed to dispose of garbage and refuse properly by not Residents Affected - Many completely covering two (2) of 2 dumpsters (a large trash container designed to be emptied into a truck) and two smaller carts for an unknown length of time.

This deficient practice had a potential to attract flies, insects, cats, and other animals to the dumpster area placing 54 of 59 facility residents getting food from the kitchen cross-contamination (a transfer of harmful bacteria from one place to another).

During a concurrent observation and interview on 6/4/2024 at 12:32p.m. with Dietary Manager (DM), it was observed there were two big garbage dumpsters full and overflowing and the lids were unable to be closed for both of the bins. Additionally, there were two extra carts in the front of the big dumpsters with disposable places with no lid. The DM stated the trash was picked up yesterday and will have another trash pickup on 6/4/2024. The DM stated the garbage bins are supposed to be sealed as it might attract flies, rodents, and cause infestation.

During a review of the facility's P&P titled, Disposal of Garbage and Refuse, revised 12/19/2022, the P&P indicated containers and dumpsters shall be kept covered when not being loaded.

During a review of Food Code 2017, indicated, 5-501.113 Covering Receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered: (A) Inside food establishment if the receptacles and units: (1) Contain food residue and are not in continuous use; or (2) After they are filled; and 174 (B) With tight-fitting lids or doors if kept outside the food establishment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 74 055758 Department of Health & Human Services Printed: 09/23/2025 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 055758 B. Wing 06/11/2024

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

Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

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 0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Level of Harm - Minimal harm or potential for actual harm 46537

Residents Affected - Many Based on interview and record review, the facility failed to identify unresolved quality deficiencies, some of which had been cited on previous surveys, and ensure actions were developed and implemented to attempt to correct the deficiencies through the quality assessment and assurance (QAA) process as evidenced by

the severity and number of deficiencies cited involving sufficient staffing, significant medication error, providing medications as physician ordered, and maintaining medication in stock.

This failure had potential to result in 54 of 54 residents residing in the facility not receiving services and care

they need.

Findings:

During a review of the facility's Census and Direct Care Service Hours Per patient Day (DHPPD), dated from 4/1/2023 to 4/30/2024, the DHPPD indicated as follow:

a. 4/15/2024-Actual CNA DHPPD 2.24

b. 4/16/2024- Actual CNA DHPPD 2.40

c. 4/17/2024- Actual CNA DHPPD 2.40

d. 4/19/2024- Actual CNA DHPPD 2.29

e. 4/20/2024- Actual CNA DHPPD 2.06

During an interview on 6/6/2024, 3:21 p.m., with RNA 1, RNA 1 stated, there are two RNAs in the facility and

they would be pulled on the floor as a CNA if there was short staff. RNA 1 stated, she would have to work as CNA during the morning and work as RNA afternoon.

During a concurrent interview and record review on 6/7/2024, at 9:34 a.m., with Director of Staff Development (DSD), the facility's DHPPD from 4/15/2024 to 4/20/2024 was reviewed. The DHPPD indicated actual CNA direct care hours was equal or below the minimum hours of 2.4. DSD stated, there was two RNAs, but both were unavailable for personal issue during that period. DSD stated 28 residents had not received the RNA service during that period due to unavailability of RNA. DSD stated, there were three CNAs in training, but no one had certificate yet and could not work. DSD stated, the facility had a contract with registry (a staffing agency is a company that provides employees to work in another company on a temporary or permanent basis) but did not use the registry staff. DSD stated, the facility should have contacted registry company. DSD stated, 28 residents did not receive RNA service due to insufficient staffing and this would affect residents' overall functions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 74 055758 Department of Health & Human Services Printed: 09/23/2025 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 055758 B. Wing 06/11/2024

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

Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

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 0867 During a review of the facility's Immediate Jeopardy (a situation in which the nursing home's non-compliance with one or more requirements has caused, or is likely to cause, serious injury, harm, impairment, or death to Level of Harm - Minimal harm or a resident) Template (IJT), dated 6/6/2024, the IJT indicated, the facility failed to administer 20 medications potential for actual harm in accordance with physician orders or professional standards of practice out of 41 total opportunities to five of five residents observed for medication administration (Resident 19, 26, 209, 210, and 211.) resulting in a Residents Affected - Many medication error rate of 48.78%. The IJT indicated, metoprolol (a medication to treat high blood pressure) for Resident 26, Apixaban (a prescription medicine used to reduce the risk of stroke and blood clots) for Resident 209, Amoxicillin (medication to treat bacterial infections) for Resident 211, Lidocaine (A substance used to relieve pain by blocking signals at the nerve endings in skin) for 210 were not in stock.

During an interview on 6/11/2024, 5:28 p.m., with Administrator (ADM), ADM stated, it was eye opening to find out regarding issues with medication administration and medications in stock during IJ process. ADM stated, he was not aware of those medication issues and staffing issues. ADM stated, there was a contracted registry agency, but they did not use the service. ADM stated, it was important to provide RNA service to maintain and improve residents' optimal function. ADM stated, he would definitely discuss medication issues and staffing shortage in June Quality Assurance Performance Improvement ([QAPI] takes a systemic, interdisciplinary, comprehensive, and data driven approach to maintaining and improving safety and quality

in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving) meeting. ADM stated he realized those issues were identified in previous survey and QAPI committee meeting did not implement effective plan to resolve them. ADM state, he did not include direct resident care staff who works on the floor for QAPI meeting.

During a review of the facility's policy and procedure (P&P) titled, Quality Assurance and Performance Improvement (QAPI), revised 12/19/2022, Policy: It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides. It indicated that QAPI program includes the establishment of a Quality Assessment and Assurance (QAA) Committee and a written QAPI Plan. Tracking and measuring performance. Systematically analyzing underlying causes of systemic quality deficiencies. v. Developing and implementing corrective action or performance improvement activities. vi. Monitoring and evaluating the effectiveness of corrective action/performance improvement b. medical errors and adverse events are routinely tracked. 1. Facility staff monitor residents for medical errors and adverse events in accordance with established procedures for the type of adverse event. An investigation will be conducted on each identified medical error or adverse event to analyze causes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 74 055758 Department of Health & Human Services Printed: 09/23/2025 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 055758 B. Wing 06/11/2024

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

Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

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** 46537 potential for actual harm 49130 Residents Affected - Some Based on observation, interview and record review, the facility failed to implement infection control measures by failing to:

1.Ensure Certified Nurse Assistant (CNA) 1 performed hand hygiene during and after caring for Resident 31.

2.Ensure CNA 2 wore proper Personal Protective Equipment ([PPE]- equipment used to prevent or minimize exposure to hazards) during the care of Resident 6 who was on enhanced precaution (a level of infection control that requires interventions such as wearing gloves and a gown) and exposed Resident 211 who was not on any precaution for possible cross contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another).

These failures resulted in compromised infection control measures to prevent the spread of Covid-19 (a contagious disease caused by the virus) and other infections among residents, staff, and visitors of the facility.

3.observe infection control measures by not practicing hand hygiene, disinfecting their work area, or wearing

the appropriate personal protective equipment (PPE - gowns, gloves, masks used to protecti from and prevent the spread of infections) in between tasks of medication preparation for six of seven sampled residents during medication pass observation (Residents 26, 209, 211, 210, 19 and 47.)

These failures had the potential to contaminate medicines in the medication cart and cause the spread of infections for Residents 26, 209, 211, 19 and 47.

Findings:

1.During a review of Resident 31's Admission Record, the Admission Record indicated, Resident 31 was initially admitted to the facility on [DATE REDACTED] and last readmission was 5/12/2024 with diagnosis including extended spectrum beta lactamase ([ESBL]- enzymes produced by some bacteria that may make them resistant to some antibiotics) resistance, dermatomyositis (an uncommon inflammatory disease marked by muscle weakness and a distinctive skin rash), immunodeficiency (the decreased ability of the body to fight infections and other diseases), and cellulitis (a deep infection of the skin caused by bacteria) of right lower limb.

During a review of Resident 31's History and Physical (H&P), dated 5/13/2024, the H&P indicated, Resident 31 had the capacity to understand and make decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 74 055758 Department of Health & Human Services Printed: 09/23/2025 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 055758 B. Wing 06/11/2024

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

Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

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

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

F 0880 During a review of Resident 31's Minimum Data Set ([MDS]-a standardized assessment and care screening tool), dated 5/16/2024, the MDS indicated Resident 31 required dependent assistance (Helper does all of the Level of Harm - Minimal harm or effort) from two or more staff for roll left and right, sit to lying, lying to sitting on side of bed, toilet hygiene, potential for actual harm shower/bathe self, lower body dressing, putting on/taking off footwear, maximal assistance (helper does more than half) from one staff for upper body dressing, moderate assistance (Helper does less than half the Residents Affected - Some effort) from one staff for oral hygiene, and supervision assistance (helper provided verbal cues and/or touching/steadying and /or contact guard assistance) from one staff for eating.

During a concurrent observation and interview on 6/4/2024, at 11:16 a.m., with CNA 1 in Resident 31's room, CNA 1 was providing hygiene care and changing Resident 31. CNA 1 came out of the room and took off her gloves, then touched and lifted the trash lid/cover outside of the room. CNA 1 did not wash or sanitize her hands and went to the therapy room to bring other staff to help her. CNA 1 did not wash or sanitize her hands when she re-entered the room and put on a new pair of gloves.

After assisting Resident 31 to wheelchair, CNA 1 came out and took off her gloves. CNA 1 lifted trash lid and discard her gloves. CNA 1 did not wash or sanitize her hands and started walking toward the nursing station. CNA 1 stated, she should have washed or sanitized her hands before entering the resident's room and after providing care. CNA 1 stated, she should have washed or sanitized her hands before wearing gloves and

after taking off the gloves to prevent spreading infections for vulnerable residents.

2. During a review of Resident 6's Admission Record, the Admission Record indicated, Resident 6 was initially admitted to the facility on [DATE REDACTED] and last admission was 4/3/2024 with diagnosis including gastrostomy (a surgical operation for making an opening in the stomach), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks).

During a review of Resident 6's H&P, dated 4/12/2024, the H&P indicated, Resident 6 had fluctuating capacity to understand and make decisions.

During a review of Resident 6's MDS, dated [DATE REDACTED], the MDS indicated Resident 6 required maximal assistance (Helper does more than half the effort) from one staff for toilet hygiene, shower, lower body dressing, putting on/taking off footwear, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, toilet transfer, and moderate assistance (Helper does less than half the effort) from one staff for oral hygiene. The MDS indicated, eating was not attempted due to medical condition or safety concerns.

During a review of Resident 211's Admission Record, the Admission Record indicated, Resident 211 was admitted to the facility on [DATE REDACTED] with diagnosis including heart failure (the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen), atrial fibrillation (an irregular and often very rapid heart rhythm), and shortness of breath (the frightening sensation of being unable to breathe normally or feeling suffocated).

During a review of Resident 211's H&P, dated 5/30/2024, the H&P indicated, Resident 211 had no capacity to understand and make decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 74 055758 Department of Health & Human Services Printed: 09/23/2025 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 055758 B. Wing 06/11/2024

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

Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

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

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

F 0880 During a review of Resident 211's MDS, dated [DATE REDACTED], the MDS indicated Resident 211 required dependent assistance (Helper does all of the effort) from two or more staff for toileting hygiene, shower/bathe self, upper Level of Harm - Minimal harm or body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, sit to lying, lying to potential for actual harm sitting on side of bed, maximal assistance (helper does more than half) from one staff for roll left and right, and supervision assistance (helper provided verbal cues and/or touching/steadying and /or contact guard Residents Affected - Some assistance) from one staff for eating, oral hygiene.

During a review of Resident 211's Care Plan (CP), initiated 5/15/2024, the CP Focus indicated, Resident 211 was on Enhanced Barrier Precaution ([EBP]- an approach of targeted gown and glove use during high contact resident care activities, designed to reduce transmission of multidrug-resistant organisms) related to presence of gastrostomy. The CP Intervention indicated, donning/doffing gown and glove use for certain residents during specific high contact resident care activities.

During an observation on 6/4/2024, at 10:15 a.m., outside of the Resident 6 and 211's room, there was Enhanced Precautions signage for Resident 6 only and Resident 211 was not on any precautions.

During an observation on 6/5/2024, at 7:35 a.m. in Resident 6 and 211's room (Resident 6 and Resident 211 were roommates), Resident 211 pressed the call light to be repositioned to eat breakfast. CNA 2 came in without washing/sanitizing hands and putting the gloves on and CNA 3 came in with PPE on. After both CNAs finished repositioning Resident 211, Resident 6 asked them to be turned to her right side and raised

the head of the bed. CNA 2 took off the gloves and sanitized her hands. CNA 2 did put on new pair of gloves and assisted Resident 6 to be turned on her right side and raised head of the bed. Resident 6 asked CNA 2 to fix the blanket and CNA 2 did. CNA 2's scrub uniform was in contact with Resident 6's blanket. Resident 112 asked CNA 2 to cover her with blanket and CNA 2 took off gloves and pulled Resident 211's blanket without washing hands in between assisting the residents. CNA 3 was standing close to Resident 211 and did not assist CNA 2 after repositioning Resident 211.

During an interview on 6/5/2024, at 7:45 A.M., with CNA 2, CNA 2 stated, she should have worn her PPE

before caring for Resident 6 because Resident 6 was on enhanced precautions. CNA 2 stated, she forgot about EBP at that time. CNA 2 stated, she should have worn PPE even though Resident 211 was not on any precaution because Resident 6 might need her help during caring Resident 211. CNA 2 stated, she should have washed hands between attending two residents to prevent cross-contamination.

During an interview on 6/5/2024, at 7:56 a.m., with CNA 3, CNA 3 stated, CNA 2 should have worn PPE

before assisting Resident 6 because of EBP. CNA 3 stated, she was standing next to Resident 211's bed because she was little confused. CNA 3 stated, she was wearing PPE, but she already had contact with Resident 211, and she was not sure if she should wear new PPE or not. CNA 3 stated, it was confusing because Resident 6 was on EBP and Resident 211 was not. CNA 3 stated, she believed it would be better to place EBP residents in the same room to avoid cross- contamination.

During an interview on 6/7/2024, at 9:04 a.m., with Infection Preventionist Nurse (IPN), the IPN stated, hand washing was important to prevent spreading infection. IPN stated, hand washing was the first line of defense from microorganisms (An organism that can be seen only through a microscope). The IPN stated, PPE should be worn before caring for residents who are on enhanced precautions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of 74 055758 Department of Health & Human Services Printed: 09/23/2025 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 055758 B. Wing 06/11/2024

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

Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

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 6/11/2024, at 3:48 p.m., with Director of Nursing (DON), the DON stated, staff should have washed or sanitized their hands before and after caring the resident to control spreading infection. The Level of Harm - Minimal harm or DON stated, she would work with IPN to cohort EBP residents together and provide in-service to staff potential for actual harm regarding EBP to prevent cross-contamination.

Residents Affected - Some 3a. During a review of Resident 26's Admission Record (a document containing demographic and diagnostic information), dated 6/4/2024, the admission record indicated, Resident 26 was admitted to the facility on [DATE REDACTED] with diagnoses including end stage renal disease (a medical condition where kidneys stop functioning with the need for regular course of long-term dialysis [a procedure to remove waste products and excess fluid from the blood]), essential (primary) hypertension and atherosclerosis (a medical condition with buildup of fat and calcium) of arteries of extremities with intermittent claudication (a medical term used to describe pain caused by reduced blood flow to the legs or arms), right leg.

During an observation on 6/4/2024 at 8:47 a.m. during medication administration, Licensed Vocational Nurse (LVN) 1 prepared medications to administer to Resident 26. LVN 1 di not disinfect the medication tray or medication cart counter before and after medication administration.

3b. During a review of Resident 209's Admission Record, dated 6/4/2024, the admission record indicated,

she was admitted to the facility on [DATE REDACTED] with diagnoses including paroxysmal atrial fibrillation (a medical condition characterized with abnormal heart beats), chronic systolic (congestive) heart failure (CHF - a medical condition where heart cannot pump blood well enough to give normal supply throughout body), essential (primary) hypertension, and atherosclerosis of aorta (a medical term used for the large blood vessel of the body.)

During an observation on 6/4/2024 at 9:10 a.m. of medication administration, LVN 1 prepared medications to administer to Resident 209. LVN 1 disinfected blood pressure monitor cuff before taking blood pressure for Resident 209. LVN 1 was not observed disinfecting medication tray or medication cart counter before entering and after exiting Resident 209's room.

3c. During a review of Resident 211's Admission Record, dated 6/4/2024, the admission record indicated, Resident 211 was admitted to the facility on [DATE REDACTED] with diagnoses including hypertensive heart disease with heart failure, atherosclerotic heart disease of native coronary artery (a medical term for blood vessel supplying blood to the heart) with unstable angina pectoris (a medical condition in which heart does not get enough blood flow and oxygen), unspecified atrial fibrillation, edema (a medical term used to describe swelling caused by too much fluid in the body's tissues) unspecified, and encounter for palliative care (a medical term used for special care provided for people living with a serious illness.)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of 74 055758 Department of Health & Human Services Printed: 09/23/2025 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 055758 B. Wing 06/11/2024

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

Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

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 observation on 6/4/2024 at 9:45 a.m. outside of Resident 211's room, a sign was posted for Enhanced Precautions (a level of infection control requiring measures such as wearing gloves and gown Level of Harm - Minimal harm or use). The Enhanced Precautions sign indicated everyone must clean hands on room entry and when exiting. potential for actual harm The sign indicated providers and staff must also wear gloves and a gown for high-contact resident care activities such as caring for devices and giving medical treatments. LVN 1 entered Resident 211's room Residents Affected - Some wearing a gown but did not wear gloves. LVN 1 proceeded to take Resident 211's blood pressure and then LVN 1 stated the monitor was out of battery and will have to find a different device to take resident's blood pressure. LVN 1 found a different blood pressure monitor, took Resident 211's blood pressure and administered medications to the resident. LVN 1 was not observed washing hands or disinfecting medication tray or medication cart counter before entering and after exiting Resident 211's room.

3d. During a review of Resident 210's Admission Record, dated 6/5/2024, the admission record indicated, Resident 210 was admitted to the facility on [DATE REDACTED] with diagnoses including fibromyalgia, lumbar region radiculopathy (a medical condition described by symptoms of pain, tingling, numbness due to pinched nerve along lumbar region of the spine), other symptoms and signs involving the musculoskeletal system, unspecified diastolic (congestive) heart failure, essential (primary) hypertension, and depression.

During an observation on 6/4/2024 at 10:04 a.m., LVN 1 prepared and administered 12 medications to Resident 210. LVN 1 was not observed disinfecting the medication tray or medication cart counter before entering and after exiting Resident 210's room.

3e. During a review of Resident 19's Admission Record, dated 6/4/2024, the admission record indicated, Resident 19 was admitted to the facility on [DATE REDACTED] and then readmitted on [DATE REDACTED] with diagnoses including nonrheumatic mitral (valve) insufficiency (a medical condition where the valve between left heart chambers does not close properly), acute on chronic systolic (congestive) heart failure, paroxysmal atrial fibrillation, essential (primary) hypertension, gastro-esophageal reflux disease without esophagitis, overactive bladder, and encounter for attention to gastrostomy.

During an observation on 6/4/2024 at 10:52 a.m., outside of Resident 19's room, a sign was posted for Enhanced Precautions.

During a concurrent observation and interview on 6/4/2024 at 10:52 a.m., with LVN 1, LVN 1 prepared medications to be administered to Resident 19 via gastrostomy tube (g-tube - a surgically placed tube used to administer mediations or food directly into the stomach). LVN 1 stated Resident 19 has a g-tube, and her medications must be crushed or in liquid form to administer. LVN 1 did not wash her hands or disinfect the medication tray or medication cart counter before administering medications via g-tube to Resident 19.

3f. During a review of Resident 47's Admission Record, dated 6/8/2024, the admission record indicated, Resident 47 was admitted to the facility on [DATE REDACTED] and then readmitted on [DATE REDACTED] with diagnoses including gastrostomy malfunction and encounter for attention to gastrostomy.

During a review of Resident 47's History and Physical, dated 7/26/2023, the history and physical indicated Resident 47 does not have the capacity to understand and make decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of 74 055758 Department of Health & Human Services Printed: 09/23/2025 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 055758 B. Wing 06/11/2024

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

Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

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 observation on 6/8/2024 at 4:17 p.m., outside of Resident 47's room, a sign was posted for Enhanced Precautions. Level of Harm - Minimal harm or potential for actual harm During an observation on 6/8/2024 at 4:17 p.m., LVN 5 prepared and administered one medication for Resident 47 via g-tube. LVN 5 did not wash hands before and after administering medication via g-tube to Residents Affected - Some Resident 47.

During an interview on 6/8/2024 at 7:23 p.m. with LVN 5, LVN 5 stated he would usually wash hands at the end of medications administration. LVN 5 stated he did not wash hands after g-tube administration of medications and in between patients. LVN 5 stated, it was important to perform hand hygiene as required to protect patients, to protect himself from any infections, because the resident had patient has an opening (for

the g-tube) and so Resident 47 health can be compromised with an infection.

During an interview on 6/10/2024 1:38 p.m., with the Director of Nurses (DON), the DON stated, that facility staff was supposed to wash hands before and after g-tube medication administration, otherwise it can lead to cross-contamination and infection the G-tube is an open device into the resident and that increases the risk for infection in residents being treated and other residents in the facility.

During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, dated 9/2/2022, the P&P indicated, Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE under Standard Precautions section. The P&P indicated All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment under Equipment Protocol section.

During a review of the facility's policy and procedure (P&P) titled, Hand Hygiene, revised 12/19/2022, the P&P indicated, Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Policy Explanation and Compliance Guidelines . 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table . Between resident contacts . After handling contaminated objects . Before applying and after removing personal protective equipment (PPE), including gloves . Before and after providing care to residents in isolation . After assistance with personal body functions ( e.g., elimination, hair grooming, smoking) .6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 68 of 74 055758 Department of Health & Human Services Printed: 09/23/2025 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 055758 B. Wing 06/11/2024

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

Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

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

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

F 0880 During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, revised 4/22/2024, the P&P indicated, Policy: It is the policy of this facility to implement enhanced barrier precautions Level of Harm - Minimal harm or for the prevention of transmission of multi drug-resistant organisms .Policy Explanation and Compliance potential for actual harm Guidelines: 3. Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available prior to performing task. Note: Face protection may also be needed if performing activity with risk of splash or spray Residents Affected - Some (i.e., wound irrigation, tracheostomy care). b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities .e. The Infection Preventionist will incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education .4. High-contact resident care activities include a. Dressing b. Bathing/Shower c. Transferring d. Providing hygiene e. Changing linens f. Changing briefs or assisting with toileting .5. Enhanced Barrier Precautions/Enhanced Standard Precaution should be followed outside the resident's room when performing transfers and assisting

during bathing in a shared/common shower room and when working with residents in the therapy gym, specifically when anticipating.

During an interview on 6/11/2024, at 3:48 p.m., with Director of Nursing (DON), the DON stated, staff should have washed or sanitized their hands before and after caring the resident to control spreading infection. The DON stated, she would work with IPN to cohort EBP residents together and provide in-service to staff regarding EBP to prevent cross-contamination.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 69 of 74 055758 Department of Health & Human Services Printed: 09/23/2025 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 055758 B. Wing 06/11/2024

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

Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

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** 44898 potential for actual harm Based on interview and record review the facility failed to ensure one of 18 sampled residents (Resident 47) Residents Affected - Few received the pneumonia (an infection that inflames the air sacs in one or both lungs) vaccine (a substance introduced into the system to help the body fight against infections).

This failure resulted in enhancing the potential for Resident 47 developing pneumonia and getting hospitalized on [DATE REDACTED] and again on 5/6/2024.

During a review of Resident 47's Admission Record, the admission record indicated Resident 47 was originally admitted to the facility on [DATE REDACTED] with diagnoses of but not limited to contractures (permanent shortening of muscle fibers, leading to muscle and joint stiffness), tachycardia (an abnormal heart rate over 100 beats a minute), dysphagia (difficulty in swallowing), and anoxic brain damage (damage to the brain due to a lack of oxygen supply).

During a review of Resident 47's History and Physical (H&P), dated 7/26/2023, the H&P indicated, Resident 47 does not have the capacity to understand and make decisions.

During a review of Resident 47's Minimum Data Set (MDS-a standardized assessment and care planning tool), dated 5/16/24, the MDS indicated Resident 47 was dependent on nursing staff for eating, oral hygiene, toileting, showering, dressing, personal hygiene, and repositioning from left to right. The MDS indicated Resident 47 did not attempt to reposition himself from sitting to lying, sitting to standing transferring to a chair due to medical condition or safety concerns. The MDS indicated Resident 47 did not attempt to walk or put

on or take off footwear because the resident did not perform these activities prior to the current illness, exacerbation, or injury.

During a review of Resident 47's Order Summary Report, dated 5/9/2023, the Order Summary Report indicated a Physician order for pneumococcal vaccine (PNA vaccination).

During a review of Resident 47's Order Summary Report, dated 6/28/2023, the Order Summary Report indicated a Physician order for pneumococcal vaccine (PNA vaccination).

During a review of Resident 47's Order Summary Report, dated 9/27/2023, the Order Summary Report indicated, a transfer to GACH via 911 for a diagnosis of shortness of breath (SOB) and desaturation (low blood oxygen levels).

During a review of Resident 47's GACH records, dated 10/4/2023, the GACH records indicated, Resident 47 had right lower lobe aspiration pneumonia.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 70 of 74 055758 Department of Health & Human Services Printed: 09/23/2025 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 055758 B. Wing 06/11/2024

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

Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

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 concurrent interview on 6/7/2024 at 10:30 a.m. with the Infection Prevention Nurse (IPN) and review of Resident 47's Order Summary Report dated 9/27/2023, the IPN stated on 9/27/2023 Resident 47 was Level of Harm - Minimal harm or transferred to the GACH (General Acute Care Hospital) in respiratory distress for coughing and being unable potential for actual harm to expectorate (inability to eject waste from the throat and lungs) and was diagnosed with pneumonia. The IPN stated Resident 47 returned back to the facility from the GACH on 10/5/2023. The IPN stated there is no Residents Affected - Few documentation of Resident 47 being offered the pneumonia vaccine and should have been offered the pneumonia vaccine upon admission, weekly or monthly. The IPN stated on 5/6/2024 Resident 47 had a chest x-ray (an electronic picture of bones and various tissue) done and the chest x-ray indicated Resident 47 had right upper lobe pneumonia and was started on an antibiotic (antiinfection)

medication Levaquin on 5/7/2024 to treat pneumonia.

During an interview on 6/7/2024 at 10:50 a.m. with the IPN, the IPN stated Resident 47's physician ordered

the pneumonia vaccine on 5/9/2023, 10/5/2023, and 5/31/2024. The IPN stated the licensed nurses are responsible for following up on vaccine orders. The IPN stated there is no documentation in Resident 47's chart of why the pneumonia vaccine was not given and no documentation on the MAR that Resident 47 received the pneumonia vaccine until today (6/7/2024). The IPN stated if the pneumonia vaccine is not offered or given to the residents, the residents are at risk for developing pneumonia and Resident 47 did develop pneumonia twice and had to be transferred to the GACH on one of the occasions.

During an interview with the DON on 6/11/2024 at 2:45 p.m., the DON stated if residents are not offered and do not receive the vaccine for pneumonia it places them at a higher risk for developing pneumonia. The DON stated Resident 47 had a high risk for developing pneumonia due to having a g-tube (a feeding tube used to provide nutrition to people who cannot obtain nutrition by mouth), immobility, CVA (interruption of blood flow or bleeding in a region of the brain) and dysphagia. The DON stated Resident 47 has a history of pneumonia and she does not know why Resident 47 did not receive his pneumonia vaccination until 6/7/2024.

During a review of the facility's policy and procedure (P&P) titled, Pneumococcal Vaccine (Series), dated 9/2/2022, the P&P indicated Each resident will be assessed for pneumococcal immunization upon admission. Each resident will be offered a pneumococcal immunization unless it is medically contraindicated, or the resident has already been immunized. Following assessment for any medical contraindications, the immunization may be administered in accordance with physician-approved standing orders A pneumococcal vaccination is recommended for all adults [AGE] years' and older A pneumococcal vaccination is recommended for adults 19 to [AGE] years' old who have certain chronic medical conditions or other risk factors which may include chronic lung disease, including COPD, emphysema, and asthma.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 71 of 74 055758 Department of Health & Human Services Printed: 09/23/2025 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 055758 B. Wing 06/11/2024

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

Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

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

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

F 0912 Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46537

Residents Affected - Some Based on observation, interview, and record review the facility failed to ensure 33 of 33 resident rooms met

the requirements of 80 square feet ([sq. ft.] a unit of area measurement) per residents in multi-bed resident rooms.

This deficient practice had the potential to result in an inadequate provision of safe nursing care, and privacy for the residents.

Findings:

During a review of the facility's Client Accommodations Analysis form, provided by the facility on 6/4/2024,

the facility had 33 rooms that measured less than 80 sq. ft. per resident in multi-bedrooms and two rooms that measured less than 100 sq. ft for a single bedroom. The resident rooms were as follow:

room [ROOM NUMBER] (2 beds) 143.75 sq. ft.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 72 of 74 055758 Department of Health & Human Services Printed: 09/23/2025 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 055758 B. Wing 06/11/2024

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

Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

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

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

F 0912 room [ROOM NUMBER] (2 beds) 143.75 sq. ft.

Level of Harm - Potential for room [ROOM NUMBER] (2 beds) 143.75 sq. ft. minimal harm room [ROOM NUMBER] (2 beds) 143.75 sq. ft. Residents Affected - Some room [ROOM NUMBER] (2 beds) 143.75 sq. ft.

room [ROOM NUMBER] (2 beds) 143.75 sq. ft.

room [ROOM NUMBER](2 beds) 143.75 sq. ft.

room [ROOM NUMBER] (2 beds) 143.75 sq. ft.

room [ROOM NUMBER] (3 beds) 220.00 sq. ft.

During an interview on 6/4/2024 at 4:14 p.m., with the Administrator (ADM), ADM stated he was aware of the recommendation of 80 sq. ft. per resident in multiple resident rooms. ADM stated the regulations specify room sq. ft to ensure residents have a home-like environment, are treated with dignity, and to alleviate any safety concerns. The ADM stated he had approved room waiver on 7/31/2023.

During a review of the facility's Room Waiver Letter dated on 7/20/2023, the Room Waiver Letter indicated, it was approved on 7/31/2023.

During a concurrent interview and record review 6/5/2024 at 3:00 p.m., with ADM, Room Waiver Letter dated

on 6/5/2024 was reviewed. Room waiver request letter was faxed to California Department of Public Health (CDPH) region 3 office on 6/5/2024 at 9:17 a.m. ADM stated, he faxed new request for current year.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 73 of 74 055758 Department of Health & Human Services Printed: 09/23/2025 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 055758 B. Wing 06/11/2024

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

Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

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

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

F 0912 During observations, from 6/4/2024 through 6/11/2024, the residents residing in these rooms had enough space to move freely inside the rooms. Each resident in the above rooms had beds and side tables with Level of Harm - Potential for drawers. There was adequate room for the operation and use of wheelchairs, walkers, or canes. Resident minimal harm room size did not affect the nursing care or privacy provided to the residents.

Residents Affected - Some During a review of the facility's policy and procedure (P&P) titled, Resident Rooms, revised 12/19/2022, the P&P indicated Resident bedrooms must be designed and equipped for adequate nursing care, comfort and privacy of residents. Policy Explanation and Compliance Guidelines .2. Resident bedrooms will measure at least 80 square feet per resident in multiple resident bedrooms .9. The facility shall request and/or maintain variances from the survey agency if the room variances.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 74 of 74 055758

F-Tag F760

Harm Level: TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49130

Residents Affected: Some overall medication error rate of 48.78 % affecting five of five residents observed for medication administration

F-F760

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 74 055758 Department of Health & Human Services Printed: 09/23/2025 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 055758 B. Wing 06/11/2024

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

Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

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

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

F 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Immediate **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49130 jeopardy to resident health or safety Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Twenty medication errors out of total 41 opportunities contributed to an Residents Affected - Some overall medication error rate of 48.78 % affecting five of five residents observed for medication administration (Residents 19, 26, 209, 210, and 211.) The medication errors noted were as follows:

1. Omitted administration of Metoprolol Tartrate (a medication used to treat high blood pressure) 75 milligrams ([mg] a unit of measure for weight) to Resident 26.

2. Failure to administer Clonidine (a medication used to treat high blood pressure) 0.1 mg to Resident 26 for systolic blood pressure ([SBP] - the pressure caused by heart while contracting) greater than or equal to 150 millimeters of mercury ([mmHg] - a unit measurement of pressure) parameters set by Resident 26's physician). On 6/4/2024 at 8:47 a.m., during medication pass observation Resident 26's BP was 153/52 and

the HR was 72.

3. An attempt to give Resident 209 medication Furosemide (a medication used for heart failure and high blood pressure) 20 mg outside of the physician's prescribed order to hold medication for SBP less than 110 or heart rate (HR) less than 60 beats per minute (BPM). On 6/4/2024 at 9:10 a.m., during medication pass

observation Resident 209's

BP was 97/41 and HR was 69.

4. An attempt to give Resident 209 medication Metoprolol Succinate extended release ([ER]- a medication has a slow release over time) 25 mg outside of the physician's ordered parameters to hold for SBP less than 110 or HR less than 60 BPM. On 6/4/2024 at 9:10 a.m., during medication pass observation Resident 209's BP was 97/41 and HR was 69.

5. Omitted administration to Resident 209 of Potassium Chloride (a medication used to treat low potassium [a mineral that organs such as the heart need to function properly] level) ER 10 milliequivalent ([mEq] - a unit of measure for mass).

6. Omitted administration to Resident 209 of Eliquis ([Generic name - Apixaban] a medication used to prevent and reduce the risk of blood clots formation) 2.5 mg.

7. Omitted administration to Resident 209 of Lactobacillus (a dietary supplement or probiotic used to promote normal bacterial flora of the intestinal tract).

8. Omitted administration of Amoxicillin (a medication used to treat infection) 500 mg to Resident 211.

9. Omitted application of Lidocaine (a medication used to treat localized pain) 5% cream to Resident 210.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 74 055758 Department of Health & Human Services Printed: 09/23/2025 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 055758 B. Wing 06/11/2024

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

Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

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

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

F 0759 10. Administration of Multivitamins with Minerals (a supplement used to treat vitamin and mineral deficiency) to Resident 19 via gastrostomy tube ([G-tube] a soft tube surgically placed directly into the stomach for Level of Harm - Immediate administration of medication and nutrition) instead of plain Multivitamins as ordered. jeopardy to resident health or safety 11. Incorrect medication administration technique to Resident 19 via G-tube by pushing [applying pressure to force the medication down the tube into the resident's stomach] on a syringe plunger instead of using gravity Residents Affected - Some [allowing medication to travel down the tube naturally] and without having the five milliliters ([mL] a unit of measure for liquid volume] of water flush between medications per physician order.

12. Incorrect administration technique of Vitamin C 500 mg to Resident 19 via G-tube by pushing on a syringe plunger instead of using gravity.

13. Incorrect administration technique of Aspirin (a medication used to prevent and reduce the risk of blood clots) 81 mg to Resident 19 via G-tube by pushing on a syringe plunger instead of using gravity.

14. Incorrect administration technique of Ferrous Sulfate (a medication used to treat iron deficiency) 220 mg/ mL to Resident 19 via G-tube by pushing on a syringe plunger instead of using gravity.

15. Incorrect administration technique of Metoprolol Tartrate 25 mg to Resident 19 via G-tube by pushing on

a syringe plunger instead of using gravity.

16. Incorrect administration technique of Furosemide 40 mg Resident 19 via G-tube by pushing on a syringe plunger instead of using gravity.

17. Incorrect administration technique of Docusate Sodium (a medication used to treat constipation) 100 mg to Resident 19 via G-tube by pushing on a syringe plunger instead of using gravity.

18. Incorrect administration technique of Oxybutynin (a medication used to treat overactive bladder) 5.0 mg to Resident 19 via G-tube by pushing on a syringe plunger instead of using gravity.

19. Incorrect administration technique of Pantoprazole (a medication used to treat gastroesophageal reflux disease) 40 mg to Resident 19 via G-tube by pushing on a syringe plunger instead of using gravity.

20. Incorrect administration technique of Zinc Sulfate (a dietary supplement used to treat zinc deficiency and promote wound healing) 50 mg to Resident 19 via G-tube by pushing on a syringe plunger instead of using gravity.

These failures to administer medications in accordance with the physician's orders placed Residents 19, 26, 209, 210, and 211 at risk to experience significant medical complications including, progression of infection, pain, high blood pressure, myocardial infarction (heart attack), blood clots development, stroke, G-tube dislodgement (sudden pulling out or displacement of the G tube) hospitalization and possible death.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 74 055758 Department of Health & Human Services Printed: 09/23/2025 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 055758 B. Wing 06/11/2024

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

Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

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

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

F 0759 On 6/6/2024 at 4:03 p.m., the California Department of Public Health (CDPH) called an Immediate Jeopardy (IJ) situation (a situation in which the facility's noncompliance with one or more requirements of participation Level of Harm - Immediate has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) due to overall jeopardy to resident health or medication administration error rate of 48.78 % the presence of the Administrator (ADM) and Director of safety Nursing (DON.)

Residents Affected - Some On 6/7/2024 at 4:47 p.m., the facility provided CDPH with an Immediate Jeopardy Removal Plan containing

the following immediate corrective actions:

1. A medication reconciliation for active medication orders and medication availability was completed by licensed staff for the residents listed above. Identified medication that was not available was called to the pharmacy for immediate delivery. Metoprolol Tartrate 75 mg one tablet by mouth (Resident 26). Medication was delivered on 6/5/2024. Apixaban 2.5 mg tab (Resident 209). Amoxicillin (Resident 211) was discontinued on 6/4/2024. Lidocaine (Resident 210). Resident 210 was discharged on [DATE REDACTED]. Medications available based on physician summary orders on 6/6/2024 to 6/7/2024, there were no missing medications.

2. On 6/6/2024 the Regional Nurse Consultant (RNC) provided re-education to the Director of Nursing (DON), the Director of Staff Development (DSD) and the Infection Preventionist (IP) regarding medication administration, documentation, and medication availability. RNC observed the DON, the DSD and the IP perform medication administration.

3. From 6/6/2024 to 6/7/2024, the pharmacy consultant reviewed physician orders and availability of the medications in the medication carts. There were no missing medications identified.

4. Starting on 6/6/2024 all active licensed nurses identified were provided re-education related to medication administration, documentation, and medication availability by the Director of Nurses/Designee to include medication administration competency. Those nurses who did not have medication administration competency skill check will not be allowed to work on the floor. There are 21 licensed nurses who are eligible to administer medications. Medication administration competency was initiated on 6/6/2024 and will continue until the eligible active licensed nurses have completed the course by 6/7/2024. Staff members on Family Medical Leave Act (FMLA) will be prohibited from administering medications until they have completed the competency skills. The DON, DSD, and IP observed licensed nurses conduct medication administration.

5. Resident 26 was assessed, and denied chest pain, weakness, difficulty talking. No sudden vision change was noted. Resident was placed on monitoring for medical complications due to medication administration error.

6. Resident 209 was assessed, and denied lightheadedness, and chest pain. No shortness of breath or nausea was noted. Resident was placed on monitoring for medical complications due to medication administration error.

7. Resident 211 was assessed and denied ear pain or muffled hearing. No ear drainage was noted. Resident was placed on monitoring for medical complications due to medication administration error. Resident did not have any signs / symptoms of ear infection. Medication was discontinued on 6/4/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 74 055758 Department of Health & Human Services Printed: 09/23/2025 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 055758 B. Wing 06/11/2024

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

Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

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

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

F 0759 8. Resident 19 was assessed, and resident denied stomach pain nor discomfort. No bleeding was noted. No signs and symptoms of infection noted, and resident was placed on monitoring for medical complication due Level of Harm - Immediate to medication administration error. jeopardy to resident health or safety 9. Resident 210 was discharged to home per resident and responsible party (RP) request on 6/5/2024. Resident was assessed before leaving the facility. Resident was in stable condition. No complaint of pain or Residents Affected - Some any discomfort noted upon discharge.

10. Seven residents with g-tube were re-evaluated by licensed staff for medical complications due to potential medication administration error on 6/6/2024.

11. Thirty-seven (37) residents with medications requiring parameters were re-evaluated by licensed staff for medical complications due to medication administration error. None were identified.

12. A medication reconciliation for active medication orders and medication availability were completed by licensed staff. Any identified medications not available were called to the pharmacy for immediate delivery. There were no missing medications identified.

13. On 6/6/2024 the Director of Nurses/Designee initiated re-education related to medication administration, documentation, medication availability, and re-ordering of medications by the Director of Nurses to include medication administration competency. There are 21 Licensed Nurses eligible to administer medications. Starting 6/6/2024, medication administration competency was conducted until active eligible Licensed Nurses completed by 6/7/2024 (2 staff on FMLA will not be allowed to administer meds without completing competency skills.)

14. On 6/6/2024 the Director of Nurses initiated retraining to the night shift staff on how to audit the medication carts, re-order, and track medication. The medication cart audits will be reviewed weekly by the Director of Nursing/Designee for any necessary follow-up for the next 3 months or until substantial compliance is met.

15. Quality Assurance Performance Improvement (QAPI - a facility's data driven approach to resident care quality improvement) Project was implemented on 6/6/2024. The Director of Nursing / Designee will monitor medication administration and medication availability and documentation. Any trends will be discussed on Cottage Crest Post Acute (CCPA) monthly QA meetings on every third (3rd) Wednesday of the month x (times) 3 months.

Based on observation, interview, and record review on 6/8/2024 at 7:04 p.m. after verifying the facility's implementation of the immediate corrective actions, CDPH removed the immediate jeopardy in the presence of the ADM, DON and Nurse Consultant.

Findings:

1. During observation of Licensed Vocational Nurse (LVN 1) medication administration and concurrent

interview on 6/4/2024 at 8:47 a.m., LVN 1 was observed preparing the following medications for Resident 26:

a. One tablet of Aspirin 81 mg.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 74 055758 Department of Health & Human Services Printed: 09/23/2025 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 055758 B. Wing 06/11/2024

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

Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

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

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

F 0759 b. One tablet of Clopidogrel ([Plavix]a medication used to prevent blood clots, heart attack [a medical condition when the artery sending blood and oxygen to the heart is blocked] and stroke) 75 mg. Level of Harm - Immediate jeopardy to resident health or c. One tablet of Nephro (vitamins to support kidney function) vitamins. safety d. One unit of insulin Lispro (a medication used to treat and reduce blood sugar levels) 100 units per one Residents Affected - Some milliliter (mL), subcutaneously ([SQ]- under the skin).

During concurrent interview LVN 1 stated Resident 26 had to receive one tablet of Metoprolol Tartrate 75 mg every Tuesday, Thursday, Saturday, and Sunday for hypertension, but the facility currently had no available Metoprolol Tartrate. LVN 1 stated the medication should have been ordered on Saturday 5/31/2024. LVN 1 stated she would check again in the medication room. LVN 1 stated she could not find Metoprolol Tartrate in

the medication room and would follow up with the pharmacy to obtain the missing medication.

During an interview on 6/4/2024 at 8:47 a.m. LVN 1 stated the four medications listed above were the only medications to administer to Resident 26 this morning besides the missing Metoprolol Tartrate 75 mg.

During an observation on 6/4/2024 at 9:00 a.m., Resident 26 was observed taking three medications including one tablet of Aspirin 81 mg, one tablet of Clopidogrel 75 mg, and one tablet of Nephro vitamins by mouth with water. LVN 1 was observed injecting SQ one unit of insulin Lispro to Resident 26.

During a review of Resident 26's Admission Record dated 6/4/2024, the Admission Record indicated Resident 26 was admitted to the facility on [DATE REDACTED] with diagnoses including end stage renal disease (a medical condition where kidneys stop functioning with the need for regular course of long-term dialysis [a procedure to remove waste products and excess fluid from the blood]), essential (primary) hypertension and atherosclerosis (a disease of the arteries characterized by the deposition of plaque [sticky deposit] of fatty material on their inner walls) of the right leg.

During a review of Resident 26's Order Summary Report (a list of a physician's orders ) dated 5/28/2024, the Order Summary Report indicated Resident 26 had a physician's order for the following medication:

a. Aspirin chewable 81 mg by mouth one time a day for cerebrovascular accident ([CVA] a medical condition with an interruption in the flow of blood to cells in the brain) prophylaxis (prevention), ordered on 2/21/2024 with the start date 2/22/2024.

b. Clonidine Hydrochloride (HCl) 0.1 mg, give one tablet by mouth every 8 hours as needed for hypertension if systolic blood pressure (SBP) is greater than or equal to 150, ordered 9/20/2023, start date 9/20/2023.

c. Metoprolol Tartrate 75 mg, give one tablet by mouth every Tuesday, Thursday, Saturday, and Sunday for hypertension, hold for SBP less than 110 or diastolic blood pressure ([DBP] a pressure in the arteries when

the heart rests between beats) less than 70 and pulse less than 60 beats per minute (BPM) (administer with food for enhanced absorption), order date 11/8/2023, start date 11/9/2023.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 74 055758 Department of Health & Human Services Printed: 09/23/2025 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 055758 B. Wing 06/11/2024

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

Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

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

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

F 0759 d. Clopidogrel one tablet 75 mg, by mouth one time a day for deep venous thrombosis ([DVT] - a medical term to describe blood clot formation in legs deep veins) for prophylaxis, order date 2/25/2022, start date Level of Harm - Immediate 2/26/2022. jeopardy to resident health or safety e. Renal multivitamin formula tablet (B complex-C-Folic Acid), one tablet by mouth one time a day for supplement, order date 2/25/2022, start date 2/26/2022. Residents Affected - Some f. Insulin Lispro solution 100 units per one milliliter (mL), to administer SQ two times a day for diabetes (a medical condition in which body does not produce enough insulin or when the body cannot effectively use

the insulin it produces), per sliding scale (a term used to define the dose based on blood glucose level) ordered on 2/20/2024 as follows:

1. For blood sugar level 150 - 200 = 1 unit

2. For blood sugar level 201 - 250 = 2 units

3. For blood sugar level 251 - 300 = 3 units

4. For blood sugar level 301 - 350 = 4 units

5. For blood sugar level 351 - 400 = 5 units

6. For blood sugar level above 400 = administer 6 units and notify medical doctor (MD).

During an interview on 6/4/2024 at 3:19 p.m., LVN 1 stated she did not call Resident 26's physician or the pharmacy to inform about Metoprolol Tartrate was not available. LVN 1 stated she usually orders medication from the pharmacy when there are three or less medication doses remaining. LVN 1 stated she was supposed to administer Clonidine 0.1 mg to Resident 26 for BP 153/52, which is greater than or equal to 150 SBP and she forgot to give that during medication pass. LVN 1 stated by not receiving medications as prescribed, Resident 26 could have a high blood pressure placing the resident at risk for stroke with serious health complications and hospitalization .

2. On 6/4/2024 at 9:10 a.m., before medication pass, LVN 1 was observation checking Resident 209's blood pressure. Concurrently during the observation, LVN 1 stated Resident 209's BP was 97/41 and HR was 69 bpm.

During an observation of medication administration on 6/4/2024 at 9:10 a.m. LVN 1 was observed preparing

the following medications for Resident 209:

a. One tablet of Furosemide 20 mg.

b. One tablet of Metoprolol Cuccinate ER (extended release) 25 mg.

Concurrently, during an interview on 6/4/2024 at 9:10 a.m. LVN 1 stated Furosemide 20 mg and Metoprolol Cuccinate ER 25 mg were the only medications to administer to Resident 209 this morning.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 74 055758 Department of Health & Human Services Printed: 09/23/2025 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 055758 B. Wing 06/11/2024

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

Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

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

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

F 0759 During a concurrent observation and interview on 6/4/2024 at 9:20 a.m. with LVN 1 in Resident 209's room, LVN 1 was stopped by the surveyor before LVN 1 would administer Furosemide 20 mg and Metoprolol Level of Harm - Immediate Cuccinate ER 25 mg to Resident 209 and advised to discuss the medications with the surveyor in the jeopardy to resident health or hallway. LVN 1 stated she got nervous and did not realize Resident 209's BP was 97/41 and HR was 69 safety bpm. LVN 1 stated she should have held Furosemide 20 mg and Metoprolol Succinate ER 25 mg at this time as Resident 209's SBP was 97 which was less than 110. Residents Affected - Some

During a review of Resident 209's Admission Record, dated 6/4/2024, the Admission Record indicated the resident was admitted to the facility on [DATE REDACTED] with diagnoses including paroxysmal atrial fibrillation (a medical condition characterized with abnormal heart beats), chronic congestive heart failure ([CHF] - a medical condition where heart cannot pump blood well enough to give normal supply throughout body), essential (primary) hypertension, and atherosclerosis of aorta (a medical term used for the large blood vessel of the body.)

During a review of Resident 209's Order Summary Report, dated 6/4/2024, the Order Summary Report indicated Resident 209 had the following medications to be administered every day at 9:00 a.m.:

a. Apixaban 2.5 mg, one tablet by mouth two times a day for CVA prophylaxis, ordered on 5/25/2024.

b. Furosemide 20 mg, one tablet by mouth two times a day for CHF, hold for SBP less than 110 or HR less than 60, ordered on 5/25/2024.

c. Lactobacillus (probiotic or a dietary supplement) one capsule by mouth one time a day for supplement, ordered on 5/25/2024.

d. Metoprolol Succinate ER 25 mg one tablet by mouth one time a day for HTN, hold for SBP less than 110 or HR less than 60, ordered on 5/25/2024.

e. Potassium Chloride ER 10 milliequivalent (mEq), one tablet by mouth two times a day for potassium supplement ordered on 5/25/2024.

During a review of Resident 209's Medication Administration Record (MAR) for June 2024, the MAR indicated LVN 1 marked Lactobacillus, Potassium Chloride ER, and Apixaban as administered at 9:00 a.m.,

on 6/4/2024.

During a concurrent interview and record review on 6/4/2024 at 3:30 p.m., with LVN 1, Resident 209's MAR dated 6/4/2024 was reviewed. The MAR indicated Apixaban tablet 2.5 mg, Furosemide tablet 20 mg, and Lactobacillus one capsule were administered to the resident. LVN 1 stated it was a mistake to mark Apixaban, Lactobacillus and Potassium Chloride as administered to Resident 209. LVN 1 stated she thought that she gave these medications, but she did not. LVN 1 stated that not receiving the Potassium Chloride ER could cause Resident 209 low potassium levels leading to heart function complications. LVN 1 stated missing a dose of Apixaban for Resident 209 could increase the resident's risk for a stroke due to the risk for developing blood clots and deep venous thrombosis (DVT).

3. During an observation of medication pass by LVN 1 on 6/4/2024 at 9:45 a.m., LVN 1 was observed preparing the following medications for administration to Resident 211:

a. One tablet of Docusate Sodium 100 mg.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 74 055758 Department of Health & Human Services Printed: 09/23/2025 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 055758 B. Wing 06/11/2024

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

Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

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

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

F 0759 b. Four capsules of Potassium ER 10 mEq.

Level of Harm - Immediate During concurrent interview on 6/4/2024 at 9:45 a.m., LVN 1 stated Docusate Sodium 100 mg and jeopardy to resident health or Potassium ER 10 mEq were the only medications to administer to Resident 211 this morning. safety

During an observation on 6/4/2024 at 10:00 a.m. in Resident 211's room, Resident 211 observed taking Residents Affected - Some Docusate Sodium 100 mg and Potassium ER 10 mEq by mouth with water and Ensure (a supplement given as a nutrition substitute or meal replacement).

During a review of Resident 211's Admission Record, dated 6/4/2024, the Admission Record indicated Resident 211 was admitted to the facility on [DATE REDACTED] with diagnoses including hypertensive heart disease with heart failure, atherosclerotic heart disease of native coronary artery (a medical term for blood vessel supplying blood to the heart) with unstable angina pectoris (a medical condition in which heart does not get enough blood flow and oxygen), unspecified atrial fibrillation, edema (a medical term used to describe swelling caused by too much fluid in the body's tissues) unspecified, and encounter for palliative care (a medical term used for special care provided for people living with a serious illness.)

During a review of Resident 211's Order Summary Report, dated 6/4/2024, the Order Summary Report indicated Resident 211 had the following medications to be administered at 9:00 a.m.:

a. Amoxicillin 500 mg, give one capsule by mouth three times a day for ear infection for 10 days, ordered 5/29/2024, to start on 5/30/2024.

b. Docusate Sodium 100 mg, one tablet by mouth two times a day for constipation, hold for loose stools, ordered on 5/29/2024.

c. Furosemide 40 mg, one tablet by mouth one time a day for edema/HTN, hold for SBP less than 110 or HR less than 60, ordered on 5/20/2024 to start on 5/30/2024.

d. Potassium Chloride ER 10 mEq, four capsules by mouth one time a day for supplement ordered on 5/29/2024.

During a concurrent interview and record review on 6/4/2024 at 4:33 p.m. with LVN 1, Resident 211's MAR dated from 5/30/2024 to 6/4/2024 for Amoxicillin and Furosemide administration was reviewed. The MAR for Amoxicillin administration indicated the Amoxicillin was not administered 5/30/2024 to 6/4/2024. LVN 1 stated she did not have Amoxicillin in stock for Resident 211 that was why this medication was not administered to Resident 211. LVN 1 stated Resident 211's infection would not be treated without Amoxicillin. LVN 1 stated she did not have Furosemide in stock for Resident 211 and that was why Furosemide was not administered from 5/30/2024 to 6/4/2024. LVN 1 stated Resident 211 was at an increased risk for edema and high blood pressure due to facility not having Furosemide available when needed.

4. During an observation of LVN 1's medication pass to Resident 210 on 6/4/2024 at 10:04 a.m., LVN 1 was observed preparing the following medications for administration to Resident 210:

a. One tablet of Aspirin 81 mg.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 74 055758 Department of Health & Human Services Printed: 09/23/2025 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 055758 B. Wing 06/11/2024

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

Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

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

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

F 0759 b. One tablet of Carvedilol (a medication used to treat high blood pressure and heart condition) 6.25 mg.

Level of Harm - Immediate c. One tablet of Ferrous Sulfate (a medication used to treat iron deficiency) 325 mg. jeopardy to resident health or safety d. One tablet of Furosemide 20 mg.

Residents Affected - Some e. One tablet of Hydralazine (a medication used to treat high blood pressure) 50 mg.

f. One tablet of Enalapril (a medication used to treat high blood pressure) 5 mg.

g. One tablet of Hydrocodone with Acetaminophen (a combination of two medications used to relieve pain) 10 mg/ 325 mg.

h. One capsule of Pregabalin (a medication used to treat nerve pain) 100 mg.

i. One tablet of Mirabegron (a medication used to treat symptoms of overactive bladder) ER 25 mg.

j. One capsule of Duloxetine (a medication used to treat fibromyalgia [a medical condition characterized by musculoskeletal pain], depression and nerve pain) 20 mg.

k. One tablet of Propranolol (a medication used to treat high blood pressure and heart condition) 20 mg.

l. One capsule of Vitamin D (a supplement to treat vitamin D deficiency) 25 micrograms ([mcg] - a unit of measure for mass).

During an interview on 6/4/2024 at 10:04 a.m. LVN 1 stated the 12 medications listed above were the only medications to administer to Resident 210 this morning.

During medication pass observation on 6/4/2024 at 10:28 a.m., Resident 210 was observed taking all 12 medications listed above by mouth with water.

During a review of Resident 210's Admission Record, dated 6/5/2024, the Admission Record indicated, Resident 210 was admitted to the facility on [DATE REDACTED] with diagnoses including fibromyalgia, lumbar region radiculopathy (a medical condition described by symptoms of pain, tingling, numbness due to pinched nerve along lumbar region of the spine), other symptoms and signs involving the musculoskeletal system, unspecified diastolic (congestive) heart failure, essential (primary) hypertension, and depression.

During a review of Resident 210's Order Summary Report, dated 5/30/2024, the Order Summary Report indicated Resident 210 had the following medications to be administered at 9:00 a.m.:

a. Aspirin 81 one chewable tablet one time a day for CVA prophylaxis, monitor for bleeding, ordered on 5/30/2024.

b. Carvedilol 6.25 mg to give one tablet by mouth two times a day for HTN, hold for SBP less than 110 or HR less than 60, ordered on 5/30/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 74 055758 Department of Health & Human Services Printed: 09/23/2025 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 055758 B. Wing 06/11/2024

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

Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

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

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

F 0759 c. Duloxetine HCl oral capsule delayed release 20 mg, give one capsule one time a day for depression manifested by verbalization of sadness, ordered on 5/30/2024. Level of Harm - Immediate jeopardy to resident health or d. Enalapril oral tablet 5 mg, give one tablet by mouth one time a day for HTN, hold for SBP less than 110 or safety HR less than 60, ordered on 5/30/2024.

Residents Affected - Some e. Ferrous Sulfate oral tablet 325 (65) mg, give one tablet by mouth two times a day for supplement, ordered

on 5/30/2024.

f. Furosemide oral tablet 20 mg, give one tablet by mouth one time a day for HTN, hold for SBP less than 110 or HR less than 60, ordered on 5/30/2024.

g. Hydralazine HCl oral tablet 50 mg, give one tablet by mouth three times a day for HTN, for SBP greater than 160 or DBP greater than 110, hold for SBP less than 110 or HR less than 60, ordered on 5/30/2024.

h. Myrbetriq (Mirabegron) ER tablet 25 mg, give one tablet by mouth one time a day for overactive bladder ordered on 5/30/2024.

i. Norco (Hydrocodone with Acetaminophen) oral tablet 10/325 mg, give one tablet by mouth every six hours as needed for severe pain (level 8 -10) not to exceed three grams ([gm] - a unit of measure for mass) of Acetaminophen in 24 hours, ordered on 5/30/2024.

j. Pregabalin oral capsule 100 mg, give one capsule by mouth two times a day for neuropathy, ordered on 5/30/2024.

k. Propranolol HCl oral tablet 20 mg, give one tablet by mouth two times a day for HTN, hold for SBP less than 110 or HR less than 60, ordered on 5/30/2024.

l. Vitamin D3 oral capsule 50 mcg, give one capsule by mouth one time a day for supplement, ordered on 5/30/2024.

m. Lidocaine external cream 5%, apply to affected site topically every 12 hours for arthritic pain, ordered on 5/30/2024.

During an interview on 6/4/2024 at 4:22 p.m., LVN 1 stated she did not have Lidocaine cream in stock for Resident 210. LVN 1 stated Resident 210 would not receive topical treatment for pain, making her uncomfortable.

4. During an observation of medication pass by LVN 1 and concurrent interview on 6/4/2024 at 10:52 a.m., LVN 1 was observed preparing the following medications for administration to Resident 19:

a. One tablet of Vitamin C 500 mg.

b. One tablet of Aspirin 81 mg.

c. Seven and a half (7.5) mL of Ferrous Sulfate elixir 220 mg/5 mL.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 74 055758 Department of Health & Human Services Printed: 09/23/2025 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 055758 B. Wing 06/11/2024

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

Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

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

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

F 0759 d. One tablet of Metoprolol Tartrate 25 mg.

Level of Harm - Immediate e. One tablet of Furosemide 40 mg. jeopardy to resident health or safety f. One tablet of Docusate Sodium 100 mg.

Residents Affected - Some g. One tablet of Multivitamins with minerals.

h. One tablet of Oxybutynin 5 mg.

i. One packet of Pantoprazole 40 mg dissolved in 7.5 mL apple juice.

j. One tablet of Zinc 50 mg supplement.

LVN 1 stated Resident 19 has a G-tube, and the resident's medications must be crushed or be in liquid form to administer. LVN 1 stated the ten medications listed above were the only medications to administer to Resident 19 this morning.

During an observation on 6/4/2024 at 10:52 a.m., LVN 1 was observed placing one of each medication listed above in individual plastic packet and started crushing each medication separately using a crushing device. LVN 1 was observed pouring each powdered (crushed) medication and liquid Ferrous Sulfate into an individual small plastic water cups. LVN 1 was observed adding 15 mL of water to each cup to dissolve medication.

During an observation on 6/4/2024 at 11:02 a.m., before administering medications individually, LVN 1 was observed administering 30 mL of water onto the G-tube by pushing on a syringe plunger. LVN 1 was observed placing 60 ml syringe (a tube with a nozzle and piston or bulb, fitted with a hollow needle, used to inject or withdraw fluid in and out, used for cleaning wounds or body cavities) tip in the medicine cup and pulling syringe plunger to withdraw each medication (Vitamin C, Aspirin, Ferrous Sulfate, Metoprolol Tartrate, Furosemide, Docusate Sodium, Multivitamin with Minerals, Oxybutynin, Pantoprazole, and Zinc) individually and administering each medication, one by one, into Resident 19's G-tube by pushing the syringe plunger. Then, after administering above listed medications, LVN 1 was observed administering another 30 mL of water into Resident 19's G-tube by pushing on the syringe plunger.

During a review of Resident 19's Admission Record, dated 6/4/2024, the Admission Record indicated, Resident 19 was admitted to the facility on [DATE REDACTED] and then readmitted on [DATE REDACTED] with diagnoses including nonrheumatic mitral (valve) insufficiency (a medical condition where the valve between left heart chambers does not close properly), acute on chronic systolic (congestive) heart failure, atrial fibrillation, essential (primary) hypertension, gastro-esophageal reflux disease without esophagitis, overactive bladder, and encounter for attention to gastrostomy.

During a review of Resident 19's Order Summary Report, dated 6/5/2024, the Order Summary Report indicated Resident 19 had the following physician's orders for medications to be administered at 9:00 a.m. every day:

a. Flushing G-tube with 15-30 mL of water before and after medication administration and with five mL of water between each medication every shift ordered on 5/19/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 74 055758 Department of Health & Human Services Printed: 09/23/2025 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 055758 B. Wing 06/11/2024

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

Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

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

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

F 0759 b. Vitamin C 500 mg one tablet via G-tube one time a day for supplement, ordered on 5/19/2024.

Level of Harm - Immediate c. Aspirin 81 mg chewable tablet to give one tablet via G-tube one time a day for CVA prophylaxis, ordered jeopardy to resident health or on 5/21/2024. safety d. Docusate Sodium 100 mg to give one tablet via G-tube two times a day for bowel management, hold if Residents Affected - Some loose stools, ordered on 5/19/2024.

e. Ferrous Sulfate oral solution 220 mg/5 mL, give seven and a half (7.5) mL via G-tube one time a day for supplement, ordered on 5/19/2024.

f. Furosemide 40 mg to give one tablet via G-tube one time a day for HTN, hold if SBP less than 110, HR less than 60, ordered on 5/19/2024.

g. Metoprolol Tartrate 25 mg, give one tablet via G-tube two times a day for HTN, hold if SBP less than 110, HR less than 60, ordered on 5/19/2024.

h. Multivitamins, give one tablet via G-tube one time a day for supplement, ordered on 5/19/2024.

i. Oxybutynin Chloride 5 mg, give one tablet via G-tube two times a day for overactive bladder, ordered on 5/19/2024.

j. Pantoprazole oral tablet delayed release 40 mg, give one tablet via G-tube two times a day for gastroesophageal reflux disease ([GERD] - a medical condition in which the stomach contents move up into

the esophagus [the part of the alimentary canal that connects the throat to the stomach]), ordered on 5/19/2024.

k. Vitamin D3 oral capsule 50 mcg, give one capsule via G-tube one time a day for

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 74 055758 Department of Health & Human Services Printed: 09/23/2025 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 055758 B. Wing 06/11/2024

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

Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

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** 46415 potential for actual harm 49130 Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors for two of seven sampled residents (Residents 26 and 209) by failing to administer metoprolol tartrate (a medication used to treat high blood pressure [BP]), clonidine (a medication used to treat high blood pressure), metoprolol succinate (a medication used to treat high blood pressure) extended release (ER - a medication formulation aiding the medication release slowly over time), apixaban (a medication used to prevent and reduce the risk of blood clot), and furosemide (a medication for heart failure and high blood pressure) in accordance with physician orders or professional standards of practice.

These failures had the potential to result in significant medical complications resulting in hospitalization or death due to stroke (a medical condition when something blocks blood supply to brain or when blood vessel

in the brain bursts), poor blood pressure control, edema (a medical term used to describe swelling caused by too much fluid in the body's tissues) and heart failure (a medical condition where heart cannot pump blood well enough to give normal supply throughout body).

Findings:

1. During a review of Resident 26's Admission Record (a document containing demographic and diagnostic information), dated 6/4/2024, the admission record indicated, Resident 26 was admitted to the facility on [DATE REDACTED] with diagnoses including end stage renal disease (a medical condition where kidneys stop functioning with the need for regular course of long-term dialysis [a procedure to remove waste products and excess fluid from the blood]), essential (primary) hypertension and atherosclerosis (a medical condition with buildup of fat and calcium) of arteries of extremities with intermittent claudication (a medical term used to describe pain caused by reduced blood flow to the legs or arms), right leg.

During a review of Resident 26's History and Physical (H&P), dated 3/15/2023, the H&P indicated resident had the capacity to understand and make decisions.

During a review of Resident 26's Minimum Data Set ([MDS], a standardized assessment and care screening tool) dated 2/29/2024, the MDS indicated Resident 26 had intact cognition (mental action or process of acquiring knowledge and understanding through thought and the senses) and required partial or moderate to setup or cleanup assistance from facility staff for activities of daily living (tasks of everyday life that include eating, dressing, getting in and out of bed or chair, bathing and toileting).

During a review of Resident 26's Order Summary Report (a list of all currently active medical orders), dated 5/28/2024, the order summary report indicated the following medications in addition to other medications prepared by Licensed Vocational Nurse (LVN) 1 during medication pass observation:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 74 055758 Department of Health & Human Services Printed: 09/23/2025 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 055758 B. Wing 06/11/2024

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

Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

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 Metoprolol Tartrate 75 milligrams (mg - a unit of measure for mass), give 1 tablet by mouth one time a day every Tuesday, Thursday, Saturday, Sunday, for hypertension (HTN - a medical term used for high blood Level of Harm - Minimal harm or pressure), hold for systolic blood pressure (SBP - the pressure caused by heart while contracting) less than potential for actual harm 110 millimeters of mercury (mmHg - a measurement of pressure) or diastolic blood pressure (DBP - the pressure in the arteries when the heart rests between beats) less than 70 mmHg and pulse less than 60 Residents Affected - Some beats per minute (BPM) (administer with food for enhanced absorption), order date: 11/8/2023.

Clonidine hydrochloride 0.1 mg, give 1 tablet by mouth every 8 hours as needed for hypertension if SBP greater than or equal to 150.

During a concurrent observation and interview during medication administration with LVN 1 on 6/4/2024 at 8:47 a.m., LVN 1 prepared four medications to administer to Resident 26. LVN 1 stated Resident 26 was supposed to also receive one tablet of metoprolol tartrate 75 mg with instructions to be given every Tuesday, Thursday, Saturday, and Sunday for hypertension, hold for SBP less than 110 mmHg or DBP less than 70 mmHg and pulse less than 60 BPM, but the facility did not have medication in stock.

During a review of the pharmacy label on the empty medication bubble pack (a card prepared by the pharmacy containing the individual doses of medications) for metoprolol tartrate 75 mg on 6/4/2024 at 8:52 a. m., the label showed the medication was last refilled for a quantity of eight tablets (fourteen day-supply) on 5/19/2024.

During an interview on 6/4/2024 at 3:19 p.m., with LVN 1, LVN 1 stated she did not have a chance to call Resident 26's doctor or pharmacy to inform them about metoprolol tartrate being out of stock. LVN 1 stated

she would order medication from the pharmacy when there are three or less doses remaining for the resident. LVN 1 stated by not receiving medications as prescribed, Resident 26 could have high blood pressure and an increased risk for stroke leading to serious health complications and hospitalization .

During a phone interview on 6/6/2024 at 9:05 a.m., with registered pharmacist (RPH) 1 at pharmacy (PH) 1, RPH 1 stated the facility requested metoprolol tartrate for Resident 26 on 5/19/2024, a 14 days' supply of the medication was delivered on 5/21/2024 and another refill was requested today (6/4/2024).

2. During a review of Resident 209's Admission Record, dated 6/4/2024, the admission record indicated, she was admitted to the facility on [DATE REDACTED] with diagnoses including paroxysmal atrial fibrillation (a medical condition characterized with abnormal heart beats), chronic systolic (congestive) heart failure (CHF - a medical condition where heart cannot pump blood well enough to give normal supply throughout body), essential (primary) hypertension, and atherosclerosis of aorta (a medical term used for the large blood vessel of the body.)

During a review of Resident 209's H&P, dated 5/26/2024, the H&P indicated resident can make medical decisions with assistance of granddaughter.

During a review of Resident 209's Order Summary Report, dated 6/4/2024, the order summary report indicated the following medications in addition to other medications prepared by LVN 1 during medication pass observation:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 74 055758 Department of Health & Human Services Printed: 09/23/2025 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 055758 B. Wing 06/11/2024

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

Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

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 Apixaban 2.5 mg, give 1 tablet by mouth two times a day for CVA (cerebrovascular accident - a medical condition with an interruption in the flow of blood to cells in the brain) prophylaxis (prevention) in addition to Level of Harm - Minimal harm or other medications potential for actual harm Potassium chloride ER 10 milliequivalent (mEq - a unit of measure for mass), give 1 tablet by mouth two Residents Affected - Some times a day for potassium supplement

During an observation of LVN 1 taking BP for Resident 209 at bedside on 6/4/2024 at 9:10 a.m., LVN 1 stated BP for Resident 209 was 97/41 and HR was 69.

During an observation of medication administration on 6/4/2024 at 9:10 a.m. with LVN 1, LVN 1 prepared the following medications for Resident 209:

1. One tablet of furosemide 20 mg, hold for SBP less than 110, HR less than 60

2. One tablet of metoprolol succinate ER 25 mg, hold for SBP less than 110, HR less than 60

During an interview on 6/4/2024 at 9:10 a.m. with LVN 1, LVN 1 stated the two medications listed above were the only medications to administer to Resident 209 at that time.

During a concurrent observation and interview on 6/4/2024 at 9:20 a.m. with LVN 1 in Resident 209's room, LVN 1 was stopped by the surveyor before the medication was administered and advised to discuss the medications with the surveyor in the hallway. LVN 1 stated she got nervous and did not realize Resident 209's recorded BP and HR parameters would not permit giving medications at this time.

During an interview on 6/4/2024 at 3:19 p.m. with LVN 1, LVN 1 stated she missed to give potassium chloride to Resident 209 because she was nervous although she had the medication in her cart that morning. LVN 1 stated that not receiving potassium could cause low potassium levels for Resident 209, leading to heart complications. LVN 1 stated she did not have apixaban in stock to administer to Resident 209. LVN 1 stated missing a dose of apixaban for Resident 209, increased resident 209's risk for stroke due to risk for blood clots and deep venous thrombosis (a medical term to describe blood clot formation in deep veins in the body in the legs).

During a phone interview on 6/6/2024 at 9:05 a.m., with RPH 1 at PH 1, RPH 1 stated a seven days' supply of apixaban for Resident 209 was delivered to facility on 5/26/2024 and another refill was requested on 6/5/2024.

During an interview on 6/5/2024 at 10:51 a.m., with the Director of Nurses (DON), the DON stated licensed nurses should call pharmacy and physician when medications are unavailable. The DON stated licensed staff should check for medication that are out of stock in the emergency kit (E-kit an emergency supply of medications). The DON stated staff should order medication when three to five doses remain. The DON stated a resident's condition would not improve if he/she are not given medications on time or doses are missed. The DON stated the facility increased residents' risk for high blood pressure, edema, heart attack, hospitalization , and even death by not having medications such as furosemide, apixaban, potassium and metoprolol available for residents. The DON stated she will check medication carts at least twice per week or more frequently to ensure medication availability.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 74 055758 Department of Health & Human Services Printed: 09/23/2025 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 055758 B. Wing 06/11/2024

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

Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

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

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

F 0760 During a review of the facility's policy and procedure (P&P) titled, Medication Administration, dated 12/19/2022, the P&P indicated, Medications are administered by licensed nurses, or other staff who are Level of Harm - Minimal harm or legally authorized .as ordered by the physician and in accordance with professional standards of practice .to potential for actual harm prevent contamination or infection. Obtain and record vital signs, when applicable or per physician orders . when applicable, hold medication for those vital signs outside the physician's prescribed parameters. Residents Affected - Some

During a review of the facility's P&P titled, Medication Reordering, dated 12/19/2022, the P&P indicated, It is

the policy of this facility to provide .pharmaceutical services accurately and safely .in a timely manner to meet

the needs of each resident. Acquisition of medications should be completed .to ensure medications are administered in a timely manner. Each time a nurse is administering medications, the nurse will observe how many doses are left, that nurse will reorder the medication, time permitting.

(Cross-referenced with

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Cottage Crest Post Acute

Inspection Findings

F-Tag F755

F-Tag F760

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