Motion Picture And T.v. Hosp D/p Snf

F-F755

Findings:

During a review of Resident 39's Face Sheet, the Face Sheet indicated the facility admitted the resident on 4/18/2018.

During a record review of Resident 39's Patient Diagnosis Information, the Patient Diagnosis Information indicated the resident had diagnoses that included neurocognitive disorder with Lewy bodies (a progressive disorder characterized by the gradual decline of thinking and reasoning abilities, often accompanied by movement and sleep disturbances, and visual hallucinations) and PI of the sacral region (lower back at the base of the spine) stage two (partial-thickness loss of skin, presenting as a shallow open sore or wound).

During a review of Resident 39's Minimum Data Set (MDS - resident assessment tool) dated 3/14/2025, the MDS indicated the facility most recently admitted the resident on 8/21/2018. The MDS indicated the resident was rarely/never able to understand others and was rarely/never able to make himself understood. The MDS further indicated the resident was dependent on assistance from staff for eating, toileting, bathing, dressing, personal and oral hygiene, and mobility.

During a review of Resident 39's Care Plan (CP) titled, Pressure Injury Stage 2 on sacrum related to previous pressure injury on area, incontinence, impaired mobility, initiated 11/25/2024, the CP indicated a goal that the area would heal without complications in the next 120 days.

During a review of Resident 39's physician orders, the physician orders indicated the following treatment orders:

- Dated 3/26/2025, cleanse PI of the sacrum with wound cleansing spray, gently pat dry, apply maxorb plus silver (an antimicrobial wound dressing), cut to fit wound, cover with opti foam (a type of dressing), change dressing daily.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 76 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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

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

F 0761 - Dated 1/30/2025 and discontinued (DC'd) on 2/12/2025, mupirocin 2 %, apply ointment 1 dose topically twice a day. cleanse PI of the sacrum with warm cleansing wipes, gently pat dry, apply mupirocin ointment Level of Harm - Minimal harm or prior to application of moisture barrier cream. Indication: stage 2 pressure injury. potential for actual harm

During a concurrent observation and interview on 4/10/2025 at 11:30 a.m. with LVN 1, observed Resident Residents Affected - Few 39's wound care treatment in the resident's room. LVN 1 stated the LVNs provide daily wound care for facility residents. LVN 1 gathered the following wound care supplies from the One [NAME] Treatment Cart: mupirocin ointment placed in a clear medication cup, an opti foam dressing, cleansing spray, and the maxorb dressing. LVN 1 entered Resident 39's room with the supplies, cleansed Resident 39's wound, applied the mupirocin ointment to cover the wound, placed the maxorb dressing on top of the mupirocin ointment, then applied the opti foam dressing. Upon completion of the treatment, LVN 1 exited the resident's room.

During a follow up observation, interview, and record review on 4/10/2025 at 11:55 a.m. with LVN 1, LVN 1 reviewed Resident 39's physician orders. LVN 1 stated LVN 1 applied mupirocin ointment to Resident 39. LVN 1 stated LVN 1 always applies the mupirocin when providing Resident 39's wound care treatment. LVN 1 then reviewed Resident 39's treatment orders and noted Resident 39 did not have an active order to apply mupirocin.

During a concurrent interview and record review on 4/10/2025 at 1:13 p.m. with RN 2, RN 2 reviewed Resident 39's physician orders. RN 2 stated when a medication is discontinued, the pharmacy and the nurse receive a notification to remove the medication from the cart. RN 2 stated Resident 39's mupirocin order was discontinued on 2/12/2025 and the medication should have been removed immediately on 2/12/2025 from

the One [NAME] Treatment Cart to ensure the medication was not administered by mistake.

During an interview on 4/10/2025 at 2:02 p.m. with LVN 1, LVN 1 stated it is important to remove discontinued medication from the cart to make sure the medication is not administered by mistake and without an order. LVN 1 stated Resident 39's discontinued mupirocin ointment remained in the One [NAME] Treatment Cart and LVN 1 administered the discontinued medication to Resident 39 every day that she worked this week including 4/10/2025, 4/9/2025, 4/8/2025, and 4/7/2025. LVN 1 stated LVN 1 just saw the mupirocin ointment in the cart, grabbed it, and applied it to Resident 39.

During a follow up interview on 4/10/2025 at 2:12 p.m. with RN 3, RN 3 stated when the discontinued mupirocin was administered to Resident 39 there was the potential that the PI healing process would be affected causing a delay in healing or a decline in the resident's condition.

During a concurrent interview and record review on 4/11/2025 at 11:15 a.m. with the Director of Long Term Care (DLTC), the DLTC reviewed the facility policy and procedure regarding medication administration and medication storage. The DLTC stated medications are discontinued for a reason. The DLTC stated discontinued medication may not be an effective treatment, or a different treatment may be more appropriate. The DLTC stated the nurse who receives the notification that a medication is discontinued is responsible for removing the medication from the cart and discarding the medication, but Resident 39's discontinued mupirocin was not removed. The DLTC stated when a discontinued medication was left in the treatment cart and administered to Resident 39, there was a potential that the mupirocin would have a negative effect on the resident's healing process. The DLTC stated the facility policy was not followed when Resident 39's discontinued mupirocin was not discarded and left in the treatment cart.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 77 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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

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

F 0761 A review of the facility policy and procedure (P&P) titled, Discontinued Medications, last reviewed 3/2024, the P&P indicated discontinued medications are removed from the nursing stations to prevent the inadvertent Level of Harm - Minimal harm or administration of discontinued medications. All discontinued medications are returned immediately to the potential for actual harm pharmacy for proper disposal. In the event that the pharmacy is closed medications may be given to the Nursing Supervisor for storage in the night locker. All opened, used liquid ointments, lotions, creams, Residents Affected - Few aerosols & powders returned from patient care areas shall be destroyed/disposed of.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 78 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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 43988

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

1. One disposable cup of coffee belonging to a kitchen staff was placed on top of a metal cart outside the dry food storage area.

2. One and a half boxes of open box of dried noodles and not labeled with an open date was stored in the dry storage area

3. One open bottle of instant coffee and not labeled with an open date was stored in the dry storage area.

4. One open box of wonton chips inside an unsealed plastic bag as not labeled with an open date.

5. One container had a label peas, black eyed dried but observed brown colored short grain inside the container.

6. Observed red potatoes inside a bin that was wet.

These deficient practices had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (transfer of bacteria from one object to another) in 88 of 89 residents who receive food from the kitchen.

Findings:

During a concurrent observation during initial kitchen tour and interview on 4/7/2025 at 8:05 a.m. with the Director of Hospitality Services (DHS), observed the following:

1. One cup of disposable cup of coffee belonging to a kitchen staff was placed on top of a metal cart outside

the dry food storage area. The DHS stated there should be no personal or staff food items in the kitchen area to prevent cross contamination.

2. One and a half boxes of open box of dried noodles and not labeled with an open date in the dry storage area. The DHS stated the facility has a labeling machine that dispenses the exact date and time and that all opened items should have a label with an open date. The DHS stated both boxes of the noodles should have been labeled with an open date so the staff would know when the item or product was opened.

3. One open bottle of instant coffee and not labeled with an open date in the dry storage area. The DHS stated all opened items should have a label with an open date. The DHS stated the bottle of instant coffee should have been labeled with an open date so the staff would know when the item or product was opened.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 79 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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 4. One open box of wonton chips inside an unsealed plastic bag and was not labeled with an open date. The DHS stated all opened items should be labeled with an open date and sealed inside the plastic bag. The Level of Harm - Minimal harm or DHS stated the plastic bag containing the wonton chips should have been sealed when opened and labeled potential for actual harm with an open date to prevent contamination of the food item inside the box.

Residents Affected - Some 5. One container had a label peas, black eyed dried but observed brown colored short grain inside the container. The DHS stated the brown colored short grain inside the container did not look like dried black-eyed peas. The DHS stated the brown colored short grain in the container looks like brown rice. The DHS food items should be labeled correctly to prevent confusion. The DHS stated the container should have been labeled properly to prevent confusion with the staff.

6. Observed red potatoes inside a bin that was wet. The DHS stated produce items should be stored in a dry container. The DHS stated the red potatoes should have been stored in a dry container as it had the potential to develop mildew and cause contamination of the food item in the container.

During an interview on 4/11/2025 at 3:30 p.m. with the Director of Long-Term Care (DLTC), the DLTC stated there should be no personal food items by the kitchen staff in the kitchen food preparation area as it had the potential for cross contamination in the kitchen. The DLTC stated all opened items should be labeled with an open date so the staff would know when to discard the items. The DLTC stated all produce should be stored

in a dry container as it had the potential to develop mold. The DLTC stated the containers should be labeled properly to prevent confusion with the staff during food preparation. The DLTC all these failures placed the residents at risk for food borne illnesses.

During a review of the facility's policy and procedure (P&P) titled, Food and Supply Storage, last reviewed on 1/2025, the P&P indicated all food and non-food items and supplies used in food preparation shall be stored

in a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. The P&P further indicated:

- Cover, label, and date unused portions and open packages.

- Store potatoes in a dry, dark area.

- Store foods in their original packages. Foods that must be opened must be stores in NSF approved containers that have tight fitting lids. Label both the bin and the lid.

During a review of Food Code 2022, the Food Code 2022 indicated, 3-501.17 Commercially processed food, open and hold cold, (B) except specified in (E) - (G) of this section, refrigerated, ready-to-eat time/temperature control for food safety food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacture's use-by- date if the manufacturer determined the use-by date based on food safety.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 80 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41379

Residents Affected - Some Based on interview and record review, the facility failed to maintain timely and accurate resident medical records for two of 21 sampled residents (Residents 4 and 86) when:

a. For Resident 4, the Physical Therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) Discharge Summary (DC) and Occupational Therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Discharge Summary was not completed after PT treatment and OT treatments were completed

in 1/2025.

b. For Resident 86, the PT Discharge Summary was not completed after PT treatment was completed on 3/26/2025.

These deficient practices had the potential for inaccurate medical documentation and cause a delay in provision of appropriate interventions for Residents 4 and 86.

Findings:

a. During a review of Resident 4's Face Sheet (FS), the FS indicated Resident 4 admitted to the facility on [DATE REDACTED] with diagnoses including, but not limited to congestive heart failure (a heart disorder which causes

the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and polyarthritis (swelling and tenderness of multiple joints causing pain and stiffness).

During a review of Resident 4's Minimum Data Set (MDS, resident assessment tool) dated 2/21/2025, the MDS indicated Resident 4 had moderate cognitive impairment (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving). The MDS indicated Resident 4 had no functional limitations in range of motion (ROM, full movement potential of a joint) in both upper extremities (UE, shoulder, elbow, wrist/hand) and had impairments in ROM on both sides of the lower extremities (LE, hip, knee, ankle/foot). The MDS indicated Resident 4 required supervision for eating, substantial assistance with toileting, bathing, sit to stand, and bed to chair transfers.

During a review of Resident 4's Physical Therapy Evaluation dated 8/29/2024, the PT evaluation indicated a recommendation for PT treatment two times a week for four weeks and recommended Resident 4 for ROM and strengthening at discharge.

During a review of Resident 4's PT medical records, the PT medical records indicated the last PT treatment note was completed on 1/3/2025. There was no PT DC noted in the resident's medical record.

During a review of Resident 4's OT Evaluation dated 8/29/2024, the OT Evaluation indicated a recommendation for OT treatment two times a week for four weeks.

During a review of Resident 4's OT medical records, the OT medical records indicated the last OT treatment note was completed on 1/4/2025. There was no OT DC noted in the resident's medical record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 81 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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 0842 During an interview on 4/9/2025 at 2:51 p.m., the Registered Nurse Supervisor (RN 1) stated once a resident was discharged from PT and OT services, the therapists would write a discharge summary and Level of Harm - Minimal harm or recommendation and inform the nursing staff so that nursing could input the recommendations. potential for actual harm

During an interview and record review on 4/10/2025 at 11:04 a.m., the Therapy Manager/Occupational Residents Affected - Some Therapist (TM/OT) reviewed Resident 4's therapy medical records and stated the last OT treatment was completed on 1/4/2025 and Resident 4 was discharged from OT on 1/7/2025. TM/OT stated the OT DC should have been completed on 1/7/2025 and it was not completed. The TM/OT stated the last PT treatment was on 1/3/2025 and Resident 4 was discharged from PT on 1/7/2025. TM/OT stated the PT DC should have been completed on 1/7/2025 and it was not completed. TM/OT stated all residents that have been discharged from therapy services should have a completed DC summary. TM/OT stated the DC summary shows the resident's progress, current level of function, and recommendations at DC such as an RNA program. TM/OT stated Resident 4's RNA recommendation at therapy DC should have been for ROM and transfers and Resident 4's RNA orders should have been updated.

During a review of the facility's policies and procedures (P&P) proved 6/13/2024, titled, Inter-disciplinary Resident/Patient Assessment and Reassessment, the P&P indicated all documentation must be completed within 48 hours of service provided or service attempted.

b. During a review of Resident 86's Face Sheet (FS), the FS indicated Resident 86 admitted to the facility on [DATE REDACTED] with diagnoses including but not limited to anoxic brain damage (damage to brain due to lack of oxygen supply to the brain), hemiplegia (weakness to one side of the body) affecting right dominant side, monoplegia (paralysis of one side of the body) of upper limb affecting left nondominant side, and aphagia (a disorder that makes it difficult to speak).

During a review of Resident 86's MDS dated [DATE REDACTED], the MDS indicated was severely impaired in cognitive skills for daily decision making. The MDS indicated Resident 86 had functional limitation impairments in ROM

on both sides of the upper extremities and on one side of the lower extremities. The MDS indicated Resident 86 was dependent on staff for oral hygiene, toileting, bathing, dressing, and bed to chair transfers.

During a review of Resident 86's PT Evaluation dated 3/6/2025, the PT Evaluation indicated a recommendation for PT treatment three times a week for four weeks.

During a review of Resident 86's PT medical records, the PT medical records indicated the last PT treatment note was completed on 3/26/2025. There was no PT DC noted in the resident's medical record.

During an interview and record review on 4/9/2025 at 3:43 p.m., the Physical Therapist (PT 1) stated Resident 86's last PT treatment was completed on 3/26/2025 and was discharged from PT on 4/1/2025. PT 1 stated the PT DC was not completed. PT 1 stated it was important for therapy staff to complete DC summaries for all residents, because it informed everyone that Resident 86 was no longer on PT services. PT 1 stated it provided a summary of how the resident performed during PT, and provided recommendations

after discharge for the resident.

During a review of the facility's policies and procedures (P&P) proved 6/13/2024, titled, Inter-disciplinary Resident/Patient Assessment and Reassessment, the P&P indicated all documentation must be completed within 48 hours of service provided or service attempted.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 82 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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

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

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

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44244 potential for actual harm Based on observation, interview, and record review, the facility failed to maintain an infection prevention and Residents Affected - Some control program to help prevent the development and transmission of communicable diseases and infections for three of 21 sampled residents (Residents 47, 86, 39) investigated during the Infection Control task by failing to ensure:

1) Activities Assistant (AA) 1 donned (put on) Personal Protective Equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) upon entering Resident 47's room who was on droplet precautions (measure aimed to prevent the spread of diseases transmitted through respiratory droplets).

2) Certified Nursing Assistant (CNA 1) and Staff 1 donned an isolation gown when performing high contact activities with Resident 86 who was on Enhanced Barrier Precautions (EBP, infection control practice to reduce transmission of infectious organisms).

3) Certified Nursing Assistant (CNA 5) donned proper PPE prior to performing activities of daily living (ADL - basic tasks that must be accomplished every day for an individual to thrive) care to Resident 39 who was on EBP.

4) Linen Carts A, B, C were not covered with a loosely woven/permeable (having pores or openings that permit liquids or gases to pass through) material to protect the clean linens inside the cart.

These deficient practices had the potential to spread infections and illnesses to residents, visitors, and staff.

Findings:

1. During a review of Resident 47's Face Sheet, the Face Sheet indicated the facility admitted the resident

on 9/8/2021.

During a review of Resident 47's Patient Diagnosis Information, the Patient Diagnosis Information indicated

the resident had diagnoses including bilateral (both, left and right) osteoarthritis (a progressive disorder of

the joints, caused by a gradual loss of cartilage) of knees and hypertensive heart disease with heart failure (refers to heart problems that occur because of high blood pressure that is present over a long time, and results in heart failure in which the heart does not pump blood to the body effectively).

During a review of Resident 47's Minimum Data Set (MDS - resident assessment tool), dated 2/7/2025, the MDS indicated the facility most recently admitted the resident on 4/25/2022. The MDS indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated the resident required substantial/maximal assistance from staff for upper body dressing and was dependent on staff for toileting, bathing, lower body dressing, and chair to chair/bed transfers.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 83 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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 47's Care Plan (CP) titled, Alteration in Respiratory Function as evidenced by low grade fever, cough, nasal congestion, watery eyes, initiated 4/8/2025, the CP indicated interventions Level of Harm - Minimal harm or including the infection control nurse was notified, to test the resident for viruses, and to place the resident on potential for actual harm droplet precautions for respiratory symptoms.

Residents Affected - Some During a review of Resident 47's physician orders, dated 4/9/2025, the physician orders indicated an order for droplet precautions until 4/14/2025.

During a concurrent observation and interview, on 4/9/2025, at 9 a.m., with AA 1, outside of Resident 47's room, Resident 47 had a droplet precaution sign posted at the room entrance. Resident 47's room entrance had a closed door. AA 1 opened Resident 47's door from inside the room. AA 1 spoke with Resident 47 without a mask and exited the room. AA 1 stated he was discussing activities with Resident 47 and did not need to wear a mask or any PPE because he was not providing care to Resident 47. AA 1 looked at the droplet precaution sign and stated the sign was a different color than it was yesterday. AA 1 stated he did not read the sign prior to entering Resident 47's room. AA 1 reviewed the droplet precaution sign and stated the sign indicated droplet precautions, stop and see the nurse before entering the room, and wear a disposable surgical-grade mask when entering the resident room. AA 1 stated he was not sure why there was a droplet precaution sign on Resident 47's door but would ask the assigned nurse.

During a concurrent observation and interview, on 4/9/2025, at 9:05 a.m., with Licensed Vocational Nurse (LVN) 3 and AA 1, AA 1 spoke with LVN 3 and stated he did not wear any PPE while speaking to Resident 47 at the bedside. LVN 3 stated the droplet precaution sign was placed on the resident's door because the resident is symptomatic of a respiratory virus. LVN 3 stated AA 1 should pay attention and read the sign prior to entering the resident's room to ensure AA 1 donned a mask. AA 1 stated he did not see the sign. LVN 3 stated the importance of wearing a mask in the resident's room is to prevent the spread of contagious illnesses like the flu (a highly contagious respiratory illness, which spreads easily through the air or when people touch contaminated surfaces) or COVID-19 (a highly contagious viral infection that can trigger respiratory tract infection) to other staff, visitors, or residents.

During an interview, on 4/11/2025, at 11:15 a.m., with the Director of Long-Term Care (DLTC), the DLTC stated droplet precautions are used to prevent the transmission of infections by coughing. The DLTC stated isolation signs are posted at the entrance to a resident's room as the main method of communication with staff and visitors regarding any precautions. The DLTC stated she was made aware that AA 1 entered Resident 47's room without a mask. The DLTC stated AA 1 did not check the droplet precaution sign prior to entering Resident 47's room, but AA 1 should have. The DLTC stated the facility policy and procedure (P&P) was not followed by AA 1 and there is the potential that AA 1 may spread infections from Resident 47 to other staff and residents resulting in resident illness.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 84 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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 P&P titled, Listing of Category - Specific Isolation Precaution Techniques, last reviewed 10/2024, the P&P indicated there are two (2) levels of isolation precautions. The first, and most Level of Harm - Minimal harm or important, level are those precautions designed for the care of all residents, regardless of their diagnosis or potential for actual harm presumed infection status. These are called Standard Precautions. The second level are precautions designed only for the care of specified residents. These additional Transmission-Based Precautions are for Residents Affected - Some residents known or suspected to be infected by significant pathogens spread by airborne or droplet transmission or by contact with dry skin or contaminated surfaces. In addition to Standard Precautions, use Droplet Precautions, or the equivalent, for a patient known or suspected to be infected with microorganisms transmitted by droplets (large-particle droplets that can be generated by the patient during coughing or sneezing). In addition to standard precautions, wear a mask when working within six feet (a unit of measure) of the patient/resident.

41379

2. During a review of Resident 86's Face Sheet (FS), the FS indicated Resident 86 admitted to the facility on [DATE REDACTED] with diagnoses including but not limited to anoxic brain damage (damage to brain due to lack of oxygen supply to the brain), hemiplegia (weakness to one side of the body) affecting right dominant side, monoplegia (paralysis of one side of the body) of upper limb affecting left nondominant side, and aphagia (a disorder that makes it difficult to speak).

During a review of Resident 86's Minimum Data Set (MDS, a resident assessment tool) dated 3/11/2025, the MDS indicated was severely impaired in cognitive skills for daily decision making. The MDS indicated Resident 86 was dependent on staff for oral hygiene, toileting, bathing, dressing, and bed to chair transfers.

During a review of Resident 86's Care Plan (CP) dated 3/5/2025, the CP indicated Resident 86 was on EBP related to gastronomy tube (g-tube, a tube placed directly into the stomach for long-term feeding), wear appropriate PPE during activities of daily living, cleaning and disinfecting the environment, mobility assistance and preparing to leave the room, and transferring.

During an observation and interview on 4/8/2025 at 9:33 a.m., there was a sign outside Resident 86's room indicating EBP for Resident 86 and an isolation cart with gowns and gloves. Resident 86 was laying on the bed dressed and had a hoyer lift (a mechanical lift that allows a person to be transferred from one surface to another) sling underneath Resident 86. CNA 1 stated she was going to get assistance from another staff to transfer Resident 86 to the geriatric chair (a large, padded chair designed to help persons with limited mobility). CNA 1 exited the room and CNA 1 re-entered the room and put on gloves. Staff 1 put on gloves and entered Resident 86's room. CNA 1 and Staff 1 proceeded to transfer Resident 86 from the bed to the geriatric chair with a hoyer lift. While Resident 86 was in the geriatric chair, CNA 1 assisted Resident 86 with oral hygiene using swabs. CNA 1 and Staff 1 were not observed wearing isolation gowns while providing care inside Resident 86's room.

During an interview on 4/8/2025 at 9:46 a.m., Licensed Vocational Nurse (LVN 1) stated Resident 86 was on EBP, because Resident 86 had a g-tube. LVN 1 stated staff providing care such as transferring and hygiene for Resident 86 would need to wear an isolation gown and gloves.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 85 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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 4/8/2025 at 9:51 a.m., CNA 1 stated Resident 86 had a g-tube so staff needed to wear isolation gown and gloves when working with Resident 86. CNA 1 stated she did not wear an isolation Level of Harm - Minimal harm or gown when she assisted Resident 86 with transfers and when providing oral hygiene. CNA 1 stated staff potential for actual harm should wear PPE when there was possible contact with bodily fluids because it protected staff and the residents they worked with. CNA 1 read the EBP sign outside Resident 86's door and stated the sign Residents Affected - Some indicated to wear gown and gloves during activities such as transferring and hygiene.

During an interview on 4/9/2025 at 11:03 a.m., the Infection Preventionist (IP) stated for any resident with wounds or devices like a g-tube, staff need to follow EBP when performing close contact activities with residents. IP stated staff needed to wear isolation gowns and gloves with resident-care activities such as dressing, toileting, transferring, and oral care,.

During a review of the facility's policy and procedures (P&P) revised 3/1/2025, titled, Enhanced Barrier Precautions, the P&P indicated the need for EBP by healthcare providers while caring for residents at high-risk for MDRO transmission, presence of indwelling devices: feeding tube, wounds covered by a dressing. High-contact resident care activities for which EBP would apply: dressing, transferring, changing linens, changing briefs or assisting with toileting. Procedure: perform hand hygiene, don PPE gown, gloves upon entry and before beginning activity. Remove and discard PPE and perform hand hygiene in the room when activity is complete.

43988

3. During a review of Resident 39's Face Sheet, the Face Sheet indicated the facility admitted the resident

on 4/18/2018.

During a review of Resident 39's Clinical Record Abstract, the Clinical Record Abstract indicated Resident 39's diagnoses including neurocognitive (a decline in thinking, reasoning, and memory abilities due to a medical condition, injury, or illness affecting the brain) disorder with Lewy bodies dementia (a type of progressive dementia [a progressive state of decline in mental abilities] that leads to a decline in thinking, reasoning and independent function due to protein deposits in the brain), stage 2 pressure ulcer (partial-thickness loss of skin, presenting as a shallow open sore or wound) sacral region (a bone located at

the bottom of the spine), and retention of urine.

During a review of Resident 39's History and Physical (H&P) dated 2/17/2025, the H&P indicated the resident was non-verbal but occasionally makes eye contact and able to track voices.

During a review of Resident 39's Minimum Data Set (MDS - a resident assessment tool) dated 3/14/2025,

the MDS indicated Resident 39 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).

During a review of Resident 39's care plan (CP) on stage 2 pressure injury on sacrum initiated on 11/25/2024, the CP indicated the resident is on EBP related to wound, wear appropriate PPE during ADL as one of the interventions to assist heal the wound without complications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 86 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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 4/7/2025 at 10:18 a.m., inside Resident 39's room, observed Certified Nursing Assistant (CNA) 5 providing care to the resident and not wearing a gown. Observed a sign outside the door Level of Harm - Minimal harm or for an EBP which indicated everyone must clean their hands before entering and when leaving the room, and potential for actual harm providers and staff must wear gloves and a gown during high-contact resident care activities such as dressing, bathing, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, Residents Affected - Some device, and wound care.

During an interview on 4/7/2025 at 10:24 a.m. with CNA 5 outside Resident 39's room, CNA 5 stated he did not clean his hands prior to putting on gloves and did not put on a gown while providing care to Resident 39. CNA 5 stated he forgot that the resident was on EBP. CNA 5 stated the staff are supposed to clean their hands using the hand sanitizer and put on gloves and gown prior to providing care to residents on EBP. CNA 5 stated he should have cleaned his hands with the hand sanitizer prior to putting on gloves and wear a gown while providing care to Resident 39 to protect the spread of infection between residents.

During an interview on 4/7/2025 at 10:30 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 39 was on EBP due to presence of wound on the sacral region and the staff should wear a gown while providing care to the resident and during wound care. LVN 1 stated CNA 5 should have put on a gown while providing care to Resident 39 to prevent the spread of infection between residents.

During an interview on 4/11/2025 at 3:43 p.m. with the Director of Long-Term Care (DLTC), the DLTC stated

the staff are supposed to wear a gown during high contact activities such as dressing, bathing, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device, and wound care as indicated in the signage outside the doors. The DLTC stated CNA 5 should have performed hand hygiene prior to putting on gloves and then put on a gown while providing care to Resident 30 to protect the staff as well as spread of infection to other residents who are vulnerable.

During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, last reviewed on 3/1/2025, the P&P indicated a purpose to implement EBP as a resident-centered approach and activity approach for preventing Multidrug Resistant Organisms (MDRO - a germ, usually bacteria, that has become resistant to many different antibiotics) transmission in a healthcare setting. The P&P further indicated:

- The use of PPE by healthcare personnel during specific care activities is based on periodic assessments of

a resident's risk for MDRO colonization and transmitting MDROs.

- To assess characteristics of residents at high risk for MDRO colonization and transmission:

Wounds covered by a dressing, especially chronic wounds.

- High-contact resident care activities for which EBP would apply:

Dressing

Bathing/Showering

Transferring

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 87 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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 Changing linens

Level of Harm - Minimal harm or Changing briefs or assisting with toileting potential for actual harm Device care or use Residents Affected - Some Wound care; any skin opening requiring a dressing

- Perform hand hygiene.

- If needed, based on the procedure about to be performed to a resident, don (put on) PPE such as gown and gloves upon entry and before beginning activity.

44376

4. During a concurrent observation and interview on 4/11/2025, at 10:21 a.m., with Certified Nursing Assistant (CNA) 3, on the unit hallway, observed Linen Carts A and B covered with loosely woven/permeable cover to protect the clean linens inside the cart. CNA 3 stated the cover had tiny holes that bacteria and viruses could go through, and liquid can permeate the cover and will not totally protect the linens from environmental contaminants.

During a concurrent observation and interview on 4/11/2025, at 10:24 a.m., with CNA 4, on the unit hallway, observed linen Linen Cart C covered with loosely woven/permeable cover to protect the clean linens inside

the cart. CNA 4 stated the cover had tiny holes that bacteria and viruses could go through, and liquid can permeate the cover and will not totally protect the linens from environmental contaminants.

During a concurrent observation an interview on 4/11/2025, at 10:27 a.m., with Licensed Vocational Nurse (LVN) 3, on the unit hallway, observed Linen Carts A and B covered with loosely woven/permeable cover to protect the clean linens inside the cart. LVN 3 stated the cover was not totally protecting the linens inside the carts as air and water can penetrate the cover. LVN 3 stated viruses and bacteria were minute and can penetrate the cover and settle on the linen causing infection to residents.

During an interview on 4/11/2025, at 10:51 a.m., with the Director of Environmental Services (DEVS), the DEVS stated the covers for the linens were not totally protecting them (linens) from environmental contaminants because air and water can seep through the covers.

During an interview on 4/11/2025, at 3:23 p.m., with the Director of Long-Term Care (DLTC), the DLTC stated they should use non-permeable cover to protect the clean linens in the facility to prevent the spread of infection among residents.

During a review of the facility's recent policy and procedure (P&P) titled Linen, last reviewed on 10/2024, the P&P indicated to ensure that neither dirty laundry does not serve as a means of transmission for infection or colonization. To prevent contamination of clean linen. Clean linen should be transported in covered carts/containers.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 88 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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

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

F 0881 Implement a program that monitors antibiotic use.

Level of Harm - Minimal harm or 44376 potential for actual harm Based on interview and record review, the facility failed to reduce the risk of adverse events (an undesirable Residents Affected - Few experience or harm that happens to a patient as a result of medical care), including the development of antibiotic-resistant organisms (occurs when bacteria develop defenses against the antibiotics designed to kill them), from unnecessary or inappropriate antibiotic use for one of three sampled residents (Resident 21) reviewed for antibiotic use by failing to clarify with the ordering physician the appropriate indication of Azithromycin (also known as Zithromax, a type of antibiotic) used as a prophylaxis (an attempt to prevent disease) for pneumonia (an infection/inflammation in the lungs).

This deficient practice had the potential to cause adverse side effects and risk for resistance associated with

the use of inappropriate antibiotic therapy.

Findings:

During a review of Resident 21's Face Sheet, the Face Sheet indicated the facility admitted the resident on 11/30/2023.

During a review of Resident 21's History and Physical (H&P), dated 11/24/2024, the H&P indicated the resident was awake, alert, pleasant, and cooperative. The H&P indicated the resident had dyslipidemia (an imbalance of lipids [fats] in the blood), chronic recurrent pneumonia (two or more episodes of pneumonia [lung infection] in twelve [12] months or three episodes altogether), and atrial fibrillation (an irregular heartbeat that occurs when the electrical signals in the atria [the two upper chambers of the heart] fire rapidly at the same time). The H&P indicated, per the primary medical doctor, the resident will continue twice weekly azithromycin life-long, and daily prednisone (medication to help relieve swelling, redness, itching, and allergic reactions).

During a review of Resident 21's Minimum Data Set (MDS - a resident assessment tool), dated 2/14/2025,

the MDS indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment (a decline in thinking and memory skills that are more noticeable than what's expected for someone of a given age, but not severe enough to interfere significantly with daily life). The MDS indicated the resident was on a high-risk drug class antibiotic.

During a review of Resident 21's Active Orders, dated 11/25/2024, the Active Orders indicated an order for azithromycin 250 milligrams (mg - a unit of measurement for mass). Give 250 mg (one tablet) by mouth Monday and Friday per prescriber. Indication: pneumonia prophylaxis.

During a review of Resident 21's Plan of Care (POC) with multiple medical conditions, dated 11/30/2023, the CP indicated an intervention of azithromycin (Zithromax) 250 mg. Give 250 mg (1 tablet) by mouth Monday and Friday per prescriber. Indication: pneumonia prophylaxis.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 89 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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

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

F 0881 During a concurrent interview and record review, on 4/10/2025, at 9:07 a.m., with Registered Nurse (RN) 2, Resident 21's Active Orders, Medication Administration Record (MAR), Progress Notes, and POC were Level of Harm - Minimal harm or reviewed. RN 2 confirmed and stated there was an order for azithromycin 250 mg 1 tablet by mouth every potential for actual harm Monday and Friday for pneumonia prophylaxis. RN 2 stated there was no end date for the antibiotic and the indication is for pneumonia prophylaxis. RN 2 stated she received education from the facility regarding Residents Affected - Few antibiotic use that it should have a stop date and an appropriate indication, if used for a longer period of time,

it should have an explanation for its prolonged use. RN 2 stated their antibiotic stewardship program (a coordinated effort to ensure antibiotics are used appropriately and effectively, preventing overuse and misuse) was headed by the pharmacist and the infection prevention nurse (IP) and were responsible for making sure the antibiotics were appropriately used to prevent antibiotic resistance on residents.

During a concurrent interview and record review, on 4/10/2024, at 1:20 p.m., with Nurse Practitioner (NP) 1, Resident 21's Active Orders and Progress Notes were reviewed. NP 1 stated azithromycin for pneumonia prophylaxis is very atypical (not normal). NP 1 stated antibiotics should have an end date, and the medication was prescribed by the pulmonologist (a doctor specializing in the diagnosis and treatment of diseases and conditions of the respiratory system, which includes the lungs and airways). NP 1 stated the pharmacist, and the infection preventionist are responsible for making sure the antibiotic is appropriate and had an appropriate indication. NP 1 stated the pulmonologist's notes indicated the resident was having chronic recurrent pneumonia and per the pulmonologist azithromycin will be continued twice weekly for azithromycin life-long. The NP stated she was not aware of which clinical practice guideline they were following regarding the use of azithromycin as a prophylaxis to pneumonia. The NP stated she will contact

the provider and get back at the surveyor for which guideline they are following.

During an interview, on 4/10/2025, at 2:40 p.m., with the Director of Pharmacy (DP), the DP stated she was aware of Resident 21 having azithromycin as prophylaxis for pneumonia and there should be no end date on

the drug order. The DP stated that she had not had any discussion with the prescriber nor the IP nurse regarding its use for prophylaxis. The DP stated that if the IP brought to her attention that the indication was inappropriate, she could have asked the IP to clarify the order with the prescribing physician and asked what clinical practice guideline was used by the ordering physician. The DP stated it was important to ensure antibiotics were reviewed for its appropriate use to prevent antibiotic resistance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 90 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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

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

F 0881 During an interview, on 4/11/2024, at 9:09 a.m., with the IP, the IP stated the antibiotic stewardship program starts with the pharmacist receiving the order for antibiotics. The IP stated the pharmacist notifies her when Level of Harm - Minimal harm or there is a new order for antibiotics. The IP stated when she gets notified of new antibiotics prescribed for potential for actual harm residents, she goes to the electronic medical record (EMR) to check the assessment done by NP 1 or physician, she makes sure there is an indication, she checks the laboratory results and uses the Loeb's Residents Affected - Few criteria (a set of minimum signs and symptoms, that indicate a high likelihood of infection in a resident of a long-term care facility, potentially justifying antibiotic treatment even before confirming the infection with diagnostic tests) to check for its appropriateness of antibiotic use. The IP stated the pharmacist does not notify her if the antibiotic is being used for prophylaxis. The IP stated if she was notified of the azithromycin used as prophylaxis for pneumonia, she could have contacted the prescriber and clarified the order because

she had a recollection of discussion with a physician that azithromycin is used as a prophylaxis for bronchitis (an inflammation of the bronchial tubes, the airways that carry air to and from the lung) and chronic obstructive pulmonary disease (COPD, a group of lung diseases that cause ongoing inflammation and damage to the airways and air sacs in the lungs) only, aside from that, the order did not have a stop date, and the indication could have been clarified. The IP stated these are the type of issues she brings to Pharmacy and Therapeutics (P&T, a multidisciplinary group responsible for evaluating and recommending policies related to the safe and effective use of medications within the facility) for discussion to seek peer reviews. The IP stated the failure of the pharmacist to communicate the use of the azithromycin as a prophylaxis for pneumonia led to possible antibacterial resistance to resident.

During a concurrent interview and record review, on 4/11/2025, at 1 p.m., with NP 1, NP 1 provided an article from American Journal of Translational Research, published on 6/15/2021, which according to NP 1 was provided to her by the prescriber, indicated it can be concluded from this study that azithromycin was effective in the treatment of COPD in patients with acute exacerbation of chronic bronchitis (CB). NP 1 stated there were no mention of the study using azithromycin used as prophylaxis for pneumonia.

During an interview, on 4/11/2025, at 1:35 p.m., with the DP, the DP stated she is the first person to get the order, however she did not question the indication of azithromycin for pneumonia prophylaxis given the history of the resident. The DP denied discussing the issue with anybody, and the DP stated the issue should have been brought to P&T for discussion.

During an interview, on 4/11/2025, at 3:23 p.m., with the Director of Long-Term Care (DLTC), the DLTC stated the pharmacist should have communicated Resident 21's use of azithromycin as prophylaxis for pneumonia to the IP to clarify why the antibiotic had no stop date and to ensure the indication is appropriate for its use.

During a review of the facility's recent policy and procedure (P&P) titled, Antibiotic Stewardship, last reviewed

on 6/12/2024, the P&P indicated to provide oversight of all antibiotic prescribing within the Long Term Care unit and the Center for Behavioral Health (CBH). The goals of the program are to reduce the risk of antibiotic resistance, to minimize inappropriate prescribing of antibiotics through the development and application of appropriate provider algorithms and to educate providers, nursing staff and pharmacists on the importance of antibiotic stewardship. When the order is received in the Pharmacy, the processing pharmacist will communicate the following information, via email, to the Infection Control Nurse.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 91 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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

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

F 0881 a. Patient/Resident Name

Level of Harm - Minimal harm or b. Patient/Resident Location potential for actual harm c. Diagnosis Residents Affected - Few d. Drug, dose, route and duration.

During a review of the facility-provided Summary of Product Characteristics of Azithromycin dihydrate 200 mg/5 ml Powder for Oral Suspension, dated 5/2024, the Summary of Product Characteristics indicated for treatment of upper and lower respiratory tract infections, skin and soft tissues infections and odontostomatological (refers to the branch of medicine and science that deals with the study of teeth, the mouth, and related structures, including the jaw and face) infections 500 mg per day taken once daily, for 3 consecutive days. The same dosage regimen can be applied to elderly patients. Since elderly patients are more susceptible to developing cardiac arrythmia, particular caution is recommended due to the risk of developing cardiac arrhythmia (a problem with the heart's rhythm) and torsade de pointes (a type of very fast heart rhythm (tachycardia) that originates in the lower chambers of the heart [ventricles]).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 92 of 92 055034

F-F759)

Findings:

1. During a review of Resident 66's Face Sheet (FS- front page of the chart that contains a summary of basic information about the resident), the FS indicated the facility admitted the resident on 8/18/2023.

During a review of Resident 66's Clinical Record Abstract (CRA), the CRA indicated Resident 66 had diagnoses including dementia (a progressive state of decline in mental abilities), paraplegia (loss of movement and/or sensation, to some degree, of the legs), and seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness).

During a review of Resident 66's Minimum Data Set (MDS-a resident assessment tool), dated 3/21/2025, the MDS indicated Resident 66 had adequate hearing, clear speech, had the ability to make self understood, and usually understand others. The MDS indicated Resident 66 required substantial assistance with eating and was dependent on staff on functional abilities in mobility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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

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

F 0760 During a review of Resident 66's Orders (physician's orders), the Orders indicated:

Level of Harm - Minimal harm or - carboxymethylcellulose sodium (Refresh Tears-eye drops) 0.5 percent (%-a unit of measurement), take two potential for actual harm drops twice a day, indication for irritation or dry eye, dated 9/29/2023.

Residents Affected - Some - cetirizine hydrochloride (HCL) (Zyrtec-antihistamine helps relieve allergies), give 10 milligrams (mg-a unit of measurement), give 10 mg (1 tablet) by mouth daily, indication for pruritus (itching), dated 4/9/2024.

- Eyelid cleanser (Ocusoft lid scrub), instill one pad into both eyes, twice a day, indication for blepharitis (inflammation of the eyelid), dated 12/6/2024.

- lacosamide (Vimpat-antiseizure medication) give 150 mg, one tablet by mouth, twice a day, indication for seizure disorder, dated 8/31/2023.

- levetiracetam (Keppra- antiseizure) 500 mg, give 750 mg (1.5 tablets) by mouth, twice a day, indication for seizure disorder, dated 2/8/2024.

During a review of Resident 66's Medication Administration Record (MAR-a record of medications administered to residents), for April 2025, the MAR indicated the scheduled time for Resident 66's medications to be given at 9 a.m. included carboxymethylcellulose sodium, cetirizine hydrochloride, eyelid cleanser, lacosamide, and levetiracetam.

During a concurrent observation and interview on 4/10/2025 at 7:27 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 prepared the following medications for Resident 66: lacosamide, one tablet (tab); levetiracetam 500 mg, 1.5 tabs; cetirizine 10 mg, one tab; carboxymethylcellulose eye drops; and eyelid cleanser. LVN 1 stated she has a total of 3.5 tablets and one eye drops to give.

During an observation and interview on 4/10/2025 at 7:31 a.m. with LVN 1, at Resident 66's bedside, LVN 1 administered 3.5 tablets, and one eye drop medications to Resident 66. LVN 1 stated she completed medication administration for Resident 66.

During a concurrent interview and record review on 4/10/2025 at 7:34 a.m. with LVN 1, reviewed Resident 66's MAR for 4/10/2025. LVN 1 stated she cannot sign Resident 66's MAR with the actual time she gave the medications because the system will not allow her until 8 a.m. LVN 1 stated the medications she gave were scheduled at 9 a.m. LVN 1 stated she will continue to pass (administer) medications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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

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

F 0760 During an interview on 4/10/2025 at 7:45 a.m. with LVN 1, LVN 1 stated she has notified Residents 66's nurse practitioner weeks before (does not recall exact date) with regard to the resident's preference to Level of Harm - Minimal harm or administer the medications earlier than the scheduled time. LVN 1 stated they (licensed nurses) have one potential for actual harm hour before and one after from the scheduled time to give the medications. LVN 1 stated she was informed by the nurse practitioner and/or physician (does not recall exactly who) that if the resident continues to Residents Affected - Some request to receive the medications earlier than the scheduled time then the timing will be changed. LVN 1 stated she gave the medications earlier because when Resident 66 was up in the chair, it was difficult to administer the eye drops compared to when the resident is was still on bed. LVN 1 stated she also asked Resident 66 if he would like to receive his medications before the scheduled time and Resident 66 stated he would like to take his medications if they were ready. LVN 1 stated she gives the medications to Resident 66 outside the scheduled time about three times a week but not all the time.

During an interview on 4/11/2025 at 11:26 a.m. with the Employee Health Manager ([NAME]), the [NAME] stated medications should be administered at the scheduled time and can be administered one hour before or one hour after the scheduled time. The [NAME] stated LVN 1 should have documented the reason for giving medication early for Resident 66.

During an interview on 4/11/2025 at 1:18 p.m. with the Director of Pharmacy (DP), the DP stated their MARs have a built-in one hour before and one hour after (time frames to record medication administration). The DP stated if the medication nurse was unable to sign the MAR of Resident 66, they (licensed nurses) would need to check with the provider (resident's physician) if it is okay to give outside the scheduled time. The DP stated the MAR has specified window of when medications can be given because they do not want to give medications too early or too late. The DP stated she expects the medication nurse (licensed nurse) to notify

the provider directly or to let the pharmacy know so they (licensed nurses) can place the order. The DP stated the medication nurse should not give the medication outside of the prescribed time because it is deviating from the current order. The DP stated all medications administered should be documented on the MAR and reflect the actual time it was given.

During an interview on 4/11/2025 at 5:17 p.m. with the Director of Long-Term Care (DLTC), the DLTC stated medications should be given at the scheduled time. The DLTC stated when medications are not given at the scheduled time, Resident 66 may not get the full effect and may have potential drug interactions. The DLTC stated the medication nurse is expected to clarify with the provider regarding the timing of the medication of Resident 66 and document the communication with the provider.

During a review of the facility's P&P titled, General Administrative, last reviewed 3/2024, the P&P indicated

the purpose its policy to provide a safe and efficient medication distribution system which shall include the evaluation, selection, purchase, storage, control, dispensing and administration of all drugs, chemicals and pharmaceuticals used throughout the Motion Picture and Television Fund Hospital (MPTF) organization. The P&P indicated that All medications administered to patients must be first ordered by a physician on the MPTF medical staff or an individual who has been granted clinical privileges. Each dose of medication shall be accurately recorded in the patient's medical record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 68 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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 P&P titled, Medication Administration, last reviewed 12/5/2024, the P&P indicated Medication shall be accurately and safely administered to MPTF patients/resident by authorized Level of Harm - Minimal harm or personnel. The procedure P&P indicated the licensed nurses to Sign the eMAR after administration or potential for actual harm non-administration of all medications. The P&P indicated the six (6) Rights of Safe Medication Administration are Right Medication, Right Dose, Right Patient/Resident, Right Route, Right Time, and Right Residents Affected - Some Documentation. The P&P indicated the physician's order must include the date and time of the order, name of medication, dose, frequency, route, indication, duration, if appliable, and diagnosis.

2. During a review of Resident 19's FS, the FS indicated the facility admitted the resident on 8/7/2024.

During a review of Resident 19's CRA, the CRA indicated Resident 19 had diagnoses including dementia, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and constipation (a problem with passing stool).

During a review of Resident 19's MDS, dated [DATE REDACTED], the MDS indicated Resident 19 had minimal difficulty hearing, clear speech, had the ability to make self understood and understand others. The MDS indicated Resident 19 required staff assistance with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) and mobility.

During a review of Resident 19's Orders, the Orders indicated the following:

- donepezil HCL (Aricept-used to treat dementia), give 5 mg, one tablet by mouth daily, indication for dementia, dated 8/7/2024.

- gabapentin (Neurontin- nerve pain medication), give 100 mg, one capsule by mouth, twice a day, indication for depression m/b refusing and resistance to care, dated 12/24/2024.

- metformin extended release (Glucophage Extended Release- medication that helps lower high blood sugar) 500 mg, give 1000 mg (two tablets) by mouth, twice a day, indication for diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), dated 8/7/2024.

- pantoprazole (Protonix- decreases amount of acid produced in the stomach) 40 mg, give 40 mg, one tablet by mouth, daily, indication for gastroesophageal reflux disease (GERD- a condition in which the stomach contents move up into the esophagus), dated 8/7/2024.

- polyethylene glycol 3350 (Miralax- used to treat constipation) 15 grams (g-a unit of measurement)/dose, give 17 g (one powder) by mouth daily, mix with eight (8) ounces (oz- a unit of measurement) of liquid or juice, indication for constipation, dated 8/7/2024.

- solifenacin succinate (Vesicare- used to treat overactive bladder [OAB- a problem with bladder (organ that stores urine before leaving the body) function that causes the sudden need to urinate]) 5 mg, give 5 mg (one tablet) by mouth, daily, indication for OAB, dated 2/21/2025.

During a review of Resident 19's MAR, for April 2025, the MAR indicated the scheduled time for Resident 19's medications to be given at 9 a.m. on 4/10/2025 included donepezil HCL, gabapentin, metformin extended release, pantoprazole, polyethylene glycol 3350, and solifenacin.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 69 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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

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

F 0760 During a concurrent observation and interview on 4/10/2025 at 7:37 a.m. with LVN 1, LVN 1 prepared Resident 19's including medications: pantoprazole 40 mg, one tab; metformin 500 mg, two tabs; gabapentin Level of Harm - Minimal harm or 100 mg, one capsule; solifenacin 5 mg, one tab; donepezil 5 mg, one tab; polyethylene glycol 17 g. LVN 1 potential for actual harm stated she will administer a total of eight medications with seven tablets and one powder. LVN 1 stated she will separate buspirone and gabapentin into a separate medication cup because Resident 19 usually does Residents Affected - Some not want to take all the medications.

During a concurrent observation and interview on 4/10/2025 at 7:43 a.m. with LVN 1, at Resident 19's bedside, LVN 1 stated Resident 19 does not want to take all the medications. LVN 1 offered buspirone and gabapentin to Resident 19 which the resident took. LVN 1 offered the rest of the medications but Resident 19 refused.

During a concurrent interview and record review on 4/10/2025 at 7:44 a.m. with LVN 1, reviewed Resident 19's MAR for 4/10/2025. LVN 1 stated she cannot sign at 7:44 a.m. the medications administered because

the electronic MAR will not save the date and time she gave the medications. LVN 1 stated she will have to wait until 8 a.m. to sign Resident 19's medications.

During an interview on 4/10/2025 at 7:45 a.m. with LVN 1, LVN 1 stated she has notified Resident 19's nurse practitioner weeks before (does not recall exact date) with regard to the resident's preference to administer

the medications earlier than the scheduled time. LVN 1 stated they (licensed nurse) have one hour before and one after from the scheduled time to give the medications. LVN 1 stated she was informed by the nurse practitioner and/or physician (does not recall exactly who) that if the resident continues to request to receive

the medications earlier than the scheduled time then the timing will be changed.

During an interview on 4/11/2025 at 11:26 a.m. with the [NAME], the [NAME] stated Resident 19's medications should be administered at the scheduled time and can be administered one hour before or one hour after the scheduled time. The [NAME] stated LVN 1 should have documented the reason for giving medication early.

During an interview on 4/11/2025 at 1:18 p.m. with the DP, the DP stated their (facility) MARs have a built-in one hour before and one hour after time frames to record medication administration. The DP stated if the medication nurse was unable to sign Resident 19's MAR, they (licensed nurses) would need to check with

the provider (resident's physician) if it is okay to give outside the scheduled time. The DP stated the MAR has specified window of when medications can be given because they do not want to give medications too early or too late. The DP stated she expects the medication nurse (licensed nurse) to notify the provider directly or to let the pharmacy know so they (licensed nurses) can place the order. The DP stated the medication nurse should not give the medication outside of the prescribed time because it is deviating from

the current order. The DP stated all medications administered should be documented on the MAR and reflect

the actual time it was given.

During an interview on 4/11/2025 at 5:17 p.m. with the DLTC, the DLTC stated Resident 19's medications should have been given at the scheduled time. The DLTC stated when medications are not given at the scheduled time the resident may not get the full effect and may have potential drug interactions.The DLTC stated the medication nurse is expected to clarify with the provider regarding the timing of the medication and document the communication with the provider.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 70 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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 P&P titled, General Administrative, last reviewed 3/2024, the P&P indicated

the purpose its policy to provide a safe and efficient medication distribution system which shall include the Level of Harm - Minimal harm or evaluation, selection, purchase, storage, control, dispensing and administration of all drugs, chemicals and potential for actual harm pharmaceuticals used throughout the Motion Picture and Television Fund Hospital (MPTF) organization. The P&P indicated that All medications administered to patients must be first ordered by a physician on the Residents Affected - Some MPTF medical staff or an individual who has been granted clinical privileges. Each dose of medication shall be accurately recorded in the patient's medical record.

During a review of the facility's P&P titled, Medication Administration, last reviewed 12/5/2024, the P&P indicated Medication shall be accurately and safely administered to MPTF patients/resident by authorized personnel. The procedure P&P indicated the licensed nurses to Sign the eMAR after administration or non-administration of all medications. The P&P indicated the six (6) Rights of Safe Medication Administration are Right Medication, Right Dose, Right Patient/Resident, Right Route, Right Time, and Right Documentation. The P&P indicated the physician's order must include the date and time of the order, name of medication, dose, frequency, route, indication, duration, if appliable, and diagnosis.

3. During a review of Resident 86's FS, the FS indicated the facility admitted Resident 86 on 3/5/2025.

During a review of Resident 86's CRA, the CRA indicated Resident 86 had diagnoses including epilepsy (a condition that affects the brain and causes frequent seizures, muscle spasm (a sudden, involuntary movement in one or more muscles), neuralgia (a sharp, shocking pain that follows the path of a nerve and is due to irritation or damage to the nerve), and neuritis (inflammation of a nerve).

During a review of Resident 86's MDS, dated [DATE REDACTED], the MDS indicated Resident 86 had unclear speech, adequate hearing, rarely/never made self understood, and rarely/never understands others. The MDS indicated Resident 86 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 86 required assistance from staff with ADLs and mobility. The MDS indicated the resident had a feeding tube (a flexible tube inserted into the stomach or intestines to deliver liquid nutrition) while a resident of the facility.

During a review of Resident 86's Orders, the Orders indicated:

- gabapentin 300 mg, give 300 mg (one tablet) via g-tube three times a day, administer through the percutaneous endoscopic gastrostomy (PEG- a procedure for placing a feeding tube directly into the stomach through the abdominal wall, bypassing the mouth and esophagus) tube, indication for neuralgia and neuritis, dated 3/5/2025.

- quetiapine fumarate (Seroquel- drug used to manage abnormal condition of the mind described as involved

a loss of contact with reality) 100 mg, give 100 mg (one tablet) via g-tube three times a day via PEG tube, indications for encephalopathy (a disease that affects the function or structure of the brain) secondary to hypoxic brain injury (low levels of oxygen in the brain causing irreversible damage) m/b agitation, dated 3/6/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 71 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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 - baclofen 10 mg, give 15 mg (1.5 tablets) via g-tube, three times a day, indication for muscle spasticity of cerebral (brain) origin, dated 4/6/2025. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 86's MAR, for April 2025, the MAR indicated the scheduled time for Resident 86's medications to be given at 2 p.m. included gabapentin, quetiapine, and baclofen. Residents Affected - Some

During a concurrent observation and interview on 4/10/2025 at 1 p.m. with LVN 1, LVN 1 prepared Resident 86's medications: quetiapine 100 mg, one tab; gabapentin 300 mg, one capsule; baclofen 10 mg, 1.5 tablets. LVN 1 stated she will administer three medications, total 3.5 tablets to give. LVN 1 crushed each tablets separately in a plastic pouch and poured separately into each medication cup. Observed LVN 1 poured five to 10 ml of water into each medication cup and stirred the medications.

During an observation on 4/10/2025 at 1:10 p.m. with LVN 1, at Resident 86's bedside, LVN 1 informed Resident 86 that she (LVN 1) prepared the resident's medications to administer. LVN 1 located Resident 86's g-tube and checked g-tube residual (the amount aspirated from the stomach following administration of enteral feed) which was zero (0) ml. LVN 1 flushed Resident 86's g-tube with 30 ml of water by gravity. LVN 1 administered all three medications with no flushing of water in between medications then flushed with 30 ml of water afterwards. LVN 1 stated she had completed medication pass for Resident 86.

During an interview on 4/10/2025 at 1:24 p.m. with LVN 1, LVN 1 stated she prepared Resident 86's medications then she went inside Resident 86's room. LVN 1 stated she checked Resident 86's g-tube residual and there was none. LVN 1 stated she flushed the g-tube with 30 ml and gave the medications then flushed the g-tube another 30 ml afterwards. LVN 1 stated she did not flush the g-tube in between medications because she follows the physician's order which was to flush the g-tube before and after medication administration. LVN 1 stated there was no order to flush the g-tube in between medications.

During a concurrent interview and record review on 4/10/2025 at 2:15 p.m. with the DLTC, reviewed the facility's policy and procedure (P&P) titled, Tube Feeding Maintenance and Medication Administration, last reviewed 12/5/2024. The DLTC stated the P&P for g-tube medication administration is to check placement, patency, and residual before every scheduled medication administration time. The DLTC stated the P&P indicated #10 administer prepared medication separately (Do not mix medication) and flush with 15 ml to 30 ml (unless otherwise ordered) of water between each med (prevent air from entering the tube and follow feeding procedure). The DLTC stated medication nurses are expected to flush 15 to 30 ml between every medication unless there is an order to administer specific amount of water to flush. The DLTC stated if there is no physician's order; the standard of practice applicable to residents including Resident 86 is to flush 15 ml to 30 ml of water between medications.

During a concurrent interview and record review on 4/10/2025 at 2:47 p.m. with LVN 1, reviewed Resident 86's MAR. LVN 1 stated there was a physician's order to flush Resident 86's g-tube with 30 ml of water

before and after medication administration which she did. LVN 1 stated she did not give water flush in between medications because there was no order to flush in between medications.

During a concurrent interview and record review on 4/10/2025 at 2:55 p.m. with LVN 1, reviewed the facility's P&P titled, Tube Feeding Maintenance and Medication Administration, last reviewed 12/5/2024. LVN 1 stated she did not follow their P&P to flush in between medications and did not check Resident 86's g-tube placement and patency at every scheduled medication administration.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 72 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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

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

F 0760 During an interview on 4/11/2025 at 11:26 a.m. with the [NAME], the [NAME] stated the standard of practice for g-tube administration is to check for placement, patency, residual, flush with water before medication Level of Harm - Minimal harm or administration, in between medications, and after medication administration. The [NAME] stated flushing in potential for actual harm between medications is done as to not mix the medications. The [NAME] stated when flushing in between medications is not done, then it is the same as mixing the medications in the same cup. The [NAME] stated Residents Affected - Some LVN 1 should have followed their policy when LVN 1 administered medications to Resident 86.

During an interview on 4/11/2025 at 1:25 p.m. with the DP, the DP stated medications given through the g-tube should not be mixed and should be flushed in between medications to maintain g-tube patency and to ensure Resident 86 received the whole dose. The DP stated there is a potential for medication interactions and clogging of the g-tube.

During an interview on 4/11/2025 at 5:17 p.m. with the DLTC, the DLTC stated it is important for the medication nurse to flush in between medications because they would not know what the drug interaction for Resident 86 and this is to ensure the patency of the g-tube and that the resident receives the medications as ordered. The DLTC stated the purpose of checking for patency and placement is to ensure the g-tube is in

the right place. The DLTC stated when this is not done the resident could potentially not receive the medications or the medication could go to a different area of the body and would not be properly absorbed.

During a review of the facility's P&P titled, Tube Feeding Maintenance and Medication Administration, last reviewed 12/5/2024, the P&P indicated the purpose of the policy is to provide medication administration when unable to take orally and to monitor for signs and symptoms of infection, irritation at the stoma (a surgically created opening on the abdomen) site. The P&P indicated procedure for medication administration:

1. Check doctor's order.

2. Wash hands and prepare equipment.

3. Identify patient and explain procedure.

4. Position patient; semi-Fowler's position.

5. [NAME] (put on) gloves and check feeding tube for placement, patency, and residual.

6. For GT/JT placement check: air auscultation (a method used to listen to the sounds of the body by using a stethoscope [medical device), stomach secretions, aspiration .

7. Check gastric residual before giving medication (unless otherwise ordered).

8. If residual is greater than 100 ml, hold medication for one hour and repeat check .

9. Flush tube with 30 ml of water prior to administering medication unless physician orders different amount for flush.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 73 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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 10. Administer prepared medication separately (Do not mix medication) and flush with 15 ml to 30 ml (unless otherwise ordered) of water between each med (Prevent air from entering the tube and follow feeding Level of Harm - Minimal harm or procedure). potential for actual harm 11. After medication is administered, instill 30 mls of water to clear the tube or as GNP/ General Nurse Residents Affected - Some Practitioner (GNP)/Physician order indicates.

During a review of the facility's P&P titled, General Administrative, last reviewed 3/2024, the P&P indicated

the purpose its policy to provide a safe and efficient medication distribution system which shall include the evaluation, selection, purchase, storage, control, dispensing and administration of all drugs, chemicals and pharmaceuticals used throughout the Motion Picture and Television Fund Hospital (MPTF) organization.

During a review of the facility's P&P titled, Medication Administration, last reviewed 12/5/2024, the P&P indicated Medication shall be accurately and safely administered to MPTF patients/resident by authorized personnel.

43988

4. During a review of Resident 10's Face Sheet, the Face Sheet indicated the facility admitted the resident

on 6/30/2021.

During a review of Resident 10's Clinical Record Abstract printed on 4/11/2025, the Clinical Record Abstract indicated Resident 10's diagnoses including type 2 diabetes mellitus (DM 2-a disorder characterized by difficulty in blood sugar control and poor wound healing), anxiety disorder (mental health condition characterized by excessive and persistent worry, fear, and unease that can interfere with daily life), and chronic pain syndrome.

During a review of Resident 10's History and Physical (H&P) dated 9/27/2024, the H&P indicated Resident 10 was alert and oriented to full name, exact date, and location.

During a review of Resident 10's Minimum Data Set (MDS, a resident assessment tool), dated 3/4/2025, the indicated Resident 10 had an intact cognition (mental action or process of acquiring knowledge and understanding) and required substantial/maximal assistance to total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS further indicated Resident 10 received insulin.

During a review of Resident 10's physician's order, the physician's order dated 10/2/2024 liraglutide (Victoza - a long-acting insulin) 0.6 milligrams (mg - a unit of measurement) per 0.1 milliliter (ml - a unit of measurement), inject 1.8 mg (0.3 ml) subcutaneously daily at eight (8) a.m. for DM 2.

During a review of Resident 10's care plan (CP) titled Medical Condition: related to DM2, initiated on 6/30/2021, the CP indicated to administer liraglutide (Victoza) as one of the interventions to prevent complications or problems with medical conditions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 74 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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

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

F 0760 During a concurrent interview and record review, on 4/11/2025 at 8:57 am., reviewed Resident 10's physician's order, subcutaneous administration sites for Victoza from 1/8/2025 to 4/11/2025, and the MDS Level of Harm - Minimal harm or with Registered Nurse (RN) 1. RN 1 stated Resident 10 received insulin, had a physician's order for Victoza, potential for actual harm and were administered as follows:

Residents Affected - Some - 3/19/2025 9:26 a.m. left middle mid-thigh

- 3/20/2025 9:10 a.m. left middle mid-thigh

- 1/27/2025 9:21 a.m. right lower back of arm

- 1/28/2025 8:43 a.m. right lower back of arm

- 1/5/2025 8:59 a.m. right lower quadrant

- 1/6/2025 8:22 a.m. right lower quadrant

RN 2 stated administration sites for insulin should be rotated per standards of practice and manufacturer's guideline to prevent hardening or lumps in the skin. RN 2 stated the location of administration sites for Resident 10's insulin was not rotated. RN 2 stated Resident 10's administration sites should have been rotated to prevent pain, redness, irritation, and lumps on the resident's skin which can affect the absorption of the insulin. RN 2 stated not rotating the insulin administration sites can be considered a medication due to no following the standards of practice and manufacturer's guideline.

During an interview on 4/11/2025 a 4 p.m., with the Director of Long-Term Care (DLTC), the DLTC stated the nurses are supposed to rotate insulin administration sites according to standards of practice, and as indicated in the manufacturer's guideline. The DLTC stated the location of administration sites for Resident 10's insulin was not rotated. The DLTC stated Resident 10's administration sites for the Victoza should have been rotated to prevent adverse effects such as bruising, skin irritation, skin pits, lipodystrophy and amyloidosis which can affect absorption of the insulin. The DLTC stated not rotating the insulin administration sites can be considered a medication due to no following the standards of practice and manufacturer's guideline.

During a review of the facility-provided manufacturer's guideline for Victoza liraglutide injection1.2 mg/1.8 mg dated 11/2024, the manufacturer's guideline indicated:

- Inject Victoza SQ in the abdomen, thigh, or upper arm.

- Rotate injection sites within the same region in order to reduce the risk of cutaneous amyloidosis.

- Adverse reaction includes injection site reactions such as injection site rash and erythema (redness of the skin).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 75 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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

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

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 44244 Residents Affected - Few Based on observation, interview and record review, the facility failed to ensure medication and biologicals were stored with currently accepted professional standards for one of three sampled residents (Resident 39) reviewed during the Pressure Ulcer / Injury (PI - localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) care area by failing to ensure mupirocin (a topical medication that treats skin infections caused by bacteria) was removed from the One [NAME] Treatment Cart when the medication was discontinued on 2/12/2025.

This deficient practice resulted in Licensed Vocational Nurse (LVN) 1 administering the discontinued mupirocin to Resident 39 potentially resulting in a delay or decline in the resident's PI healing process.

Cross reference

F-F760

Findings:

1. During a review of Resident 66's Face Sheet (FS- front page of the chart that contains a summary of basic information about the resident), the FS indicated the facility admitted the resident on 8/18/2023.

During a review of Resident 66's Clinical Record Abstract (CRA), the CRA indicated Resident 66 had diagnoses including dementia (a progressive state of decline in mental abilities), paraplegia (loss of movement and/or sensation, to some degree, of the legs), and seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness).

During a review of Resident 66's Minimum Data Set (MDS-a resident assessment tool), dated 3/21/2025, the MDS indicated Resident 66 had adequate hearing, clear speech, had the ability to make self understood, and usually understand others. The MDS indicated Resident 66 required substantial assistance with eating and was dependent on staff on functional abilities in mobility.

During a review of Resident 66's Orders (physician's orders), the Orders indicated:

- carboxymethylcellulose sodium (Refresh Tears-eye drops) 0.5 percent (%-a unit of measurement), take two drops twice a day, indication for irritation or dry eye, dated 9/29/2023.

- cetirizine hydrochloride (HCL) (Zyrtec-antihistamine helps relieve allergies), give 10 milligrams (mg-a unit of measurement), give 10 mg (1 tablet) by mouth daily, indication for pruritus (itching), dated 4/9/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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 - Eyelid cleanser (Ocusoft lid scrub), instill one pad into both eyes, twice a day, indication for blepharitis (inflammation of the eyelid), dated 12/6/2024. Level of Harm - Minimal harm or potential for actual harm - lacosamide (Vimpat-antiseizure medication) give 150 mg, one tablet by mouth, twice a day, indication for seizure disorder, dated 8/31/2023. Residents Affected - Some - levetiracetam (Keppra- antiseizure) 500 mg, give 750 mg (1.5 tablets) by mouth, twice a day, indication for seizure disorder, dated 2/8/2024.

During a review of Resident 66's Medication Administration Record (MAR-a record of medications administered to residents), for April 2025, the MAR indicated the scheduled time for Resident 66's medications to be given at 9 a.m. included carboxymethylcellulose sodium, cetirizine hydrochloride, eyelid cleanser, lacosamide, and levetiracetam.

During a concurrent observation and interview on 4/10/2025 at 7:27 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 prepared the following medications for Resident 66: lacosamide, one tablet (tab); levetiracetam 500 mg, 1.5 tabs; cetirizine 10 mg, one tab; carboxymethylcellulose eye drops; and eyelid cleanser. LVN 1 stated she has a total of 3.5 tablets and one eye drops to give.

During an observation and interview on 4/10/2025 at 7:31 a.m. with LVN 1, at Resident 66's bedside, LVN 1 administered 3.5 tablets, and one eye drop medications to Resident 66. LVN 1 stated she completed medication administration for Resident 66.

During a concurrent interview and record review on 4/10/2025 at 7:34 a.m. with LVN 1, reviewed Resident 66's MAR for 4/10/2025. LVN 1 stated she cannot sign Resident 66's MAR with the actual time she gave the medications because the system will not allow her until 8 a.m. LVN 1 stated the medications she gave were scheduled at 9 a.m. LVN 1 stated she will continue to pass (administer) medications.

During an interview on 4/10/2025 at 7:45 a.m. with LVN 1, LVN 1 stated she has notified Residents 66's nurse practitioner weeks before (does not recall exact date) with regard to the resident's preference to administer the medications earlier than the scheduled time. LVN 1 stated they (licensed nurses) have one hour before and one after from the scheduled time to give the medications. LVN 1 stated she was informed by the nurse practitioner and/or physician (does not recall exactly who) that if the resident continues to request to receive the medications earlier than the scheduled time then the timing will be changed. LVN 1 stated she gave the medications earlier because when Resident 66 was up in the chair, it was difficult to administer the eye drops compared to when the resident is was still on bed. LVN 1 stated she also asked Resident 66 if he would like to receive his medications before the scheduled time and Resident 66 stated he would like to take his medications if they were ready. LVN 1 stated she gives the medications to Resident 66 outside the scheduled time about three times a week but not all the time.

During an interview on 4/11/2025 at 11:26 a.m. with the Employee Health Manager ([NAME]), the [NAME] stated medications should be administered at the scheduled time and can be administered one hour before or one hour after the scheduled time. The [NAME] stated LVN 1 should have documented the reason for giving medication early for Resident 66.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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

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

F 0759 During an interview on 4/11/2025 at 1:18 p.m. with the Director of Pharmacy (DP), the DP stated their MARs have a built-in one hour before and one hour after (time frames to record medication administration). The DP Level of Harm - Minimal harm or stated if the medication nurse was unable to sign the MAR of Resident 66, they (licensed nurses) would potential for actual harm need to check with the provider (resident's physician) if it is okay to give outside the scheduled time. The DP stated the MAR has specified window of when medications can be given because they do not want to give Residents Affected - Some medications too early or too late. The DP stated she expects the medication nurse (licensed nurse) to notify

the provider directly or to let the pharmacy know so they (licensed nurses) can place the order. The DP stated the medication nurse should not give the medication outside of the prescribed time because it is deviating from the current order. The DP stated all medications administered should be documented on the MAR and reflect the actual time it was given.

During an interview on 4/11/2025 at 5:17 p.m. with the Director of Long-Term Care (DLTC), the DLTC stated medications should be given at the scheduled time. The DLTC stated when medications are not given at the scheduled time, Resident 66 may not get the full effect and may have potential drug interactions. The DLTC stated the medication nurse is expected to clarify with the provider regarding the timing of the medication of Resident 66 and document the communication with the provider.

During a review of the facility's P&P titled, General Administrative, last reviewed 3/2024, the P&P indicated

the purpose its policy to provide a safe and efficient medication distribution system which shall include the evaluation, selection, purchase, storage, control, dispensing and administration of all drugs, chemicals and pharmaceuticals used throughout the Motion Picture and Television Fund Hospital (MPTF) organization. The P&P indicated that All medications administered to patients must be first ordered by a physician on the MPTF medical staff or an individual who has been granted clinical privileges. Each dose of medication shall be accurately recorded in the patient's medical record.

During a review of the facility's P&P titled, Medication Administration, last reviewed 12/5/2024, the P&P indicated Medication shall be accurately and safely administered to MPTF patients/resident by authorized personnel. The procedure P&P indicated the licensed nurses to Sign the eMAR after administration or non-administration of all medications. The P&P indicated the six (6) Rights of Safe Medication Administration are Right Medication, Right Dose, Right Patient/Resident, Right Route, Right Time, and Right Documentation. The P&P indicated the physician's order must include the date and time of the order, name of medication, dose, frequency, route, indication, duration, if appliable, and diagnosis.

2. During a review of Resident 19's FS, the FS indicated the facility admitted the resident on 8/7/2024.

During a review of Resident 19's CRA, the CRA indicated Resident 19 had diagnoses including dementia, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and constipation (a problem with passing stool).

During a review of Resident 19's MDS, dated [DATE REDACTED], the MDS indicated Resident 19 had minimal difficulty hearing, clear speech, had the ability to make self understood and understand others. The MDS indicated Resident 19 required staff assistance with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) and mobility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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 review of Resident 19's Orders, the Orders indicated the following:

Level of Harm - Minimal harm or - donepezil HCL (Aricept-used to treat dementia), give 5 mg, one tablet by mouth daily, indication for potential for actual harm dementia, dated 8/7/2024.

Residents Affected - Some - gabapentin (Neurontin- nerve pain medication), give 100 mg, one capsule by mouth, twice a day, indication for depression m/b refusing and resistance to care, dated 12/24/2024.

- metformin extended release (Glucophage Extended Release- medication that helps lower high blood sugar) 500 mg, give 1000 mg (two tablets) by mouth, twice a day, indication for diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), dated 8/7/2024.

- pantoprazole (Protonix- decreases amount of acid produced in the stomach) 40 mg, give 40 mg, one tablet by mouth, daily, indication for gastroesophageal reflux disease (GERD- a condition in which the stomach contents move up into the esophagus), dated 8/7/2024.

- polyethylene glycol 3350 (Miralax- used to treat constipation) 15 grams (g-a unit of measurement)/dose, give 17 g (one powder) by mouth daily, mix with eight (8) ounces (oz- a unit of measurement) of liquid or juice, indication for constipation, dated 8/7/2024.

- solifenacin succinate (Vesicare- used to treat overactive bladder [OAB- a problem with bladder (organ that stores urine before leaving the body) function that causes the sudden need to urinate]) 5 mg, give 5 mg (one tablet) by mouth, daily, indication for OAB, dated 2/21/2025.

-

During a review of Resident 19's MAR, for April 2025, the MAR indicated the scheduled time for Resident 19's medications to be given at 9 a.m. on 4/10/2025 included donepezil HCL, gabapentin, metformin extended release, pantoprazole, polyethylene glycol 3350, and solifenacin.

During a concurrent observation and interview on 4/10/2025 at 7:37 a.m. with LVN 1, LVN 1 prepared Resident 19's including medications: pantoprazole 40 mg, one tab; metformin 500 mg, two tabs; gabapentin 100 mg, one capsule; solifenacin 5 mg, one tab; donepezil 5 mg, one tab; polyethylene glycol 17 g. LVN 1 stated she will administer a total of eight medications with seven tablets and one powder. LVN 1 stated she will separate buspirone and gabapentin into a separate medication cup because Resident 19 usually does not want to take all the medications.

During a concurrent observation and interview on 4/10/2025 at 7:43 a.m. with LVN 1, at Resident 19's bedside, LVN 1 stated Resident 19 does not want to take all the medications. LVN 1 offered two tablets, buspirone and gabapentin, to Resident 19, Resident 19 agreed. Resident 19 took the two tablets. LVN 1 offered the rest of the medications and Resident 19 refused.

During a concurrent interview and record review on 4/10/2025 at 7:44 a.m. with LVN 1, reviewed Resident 19's MAR for 4/10/2025. LVN 1 stated she cannot sign at 7:44 a.m. the medications administered because

the electronic MAR will not save the date and time she gave the medications. LVN 1 stated she will have to wait until 8 a.m. to sign Resident 19's medications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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

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

F 0759 During an interview on 4/10/2025 at 7:45 a.m. with LVN 1, LVN 1 stated she has notified Resident 19's nurse practitioner weeks before (does not recall exact date) with regard to the resident's preference to administer Level of Harm - Minimal harm or the medications earlier than the scheduled time. LVN 1 stated they (licensed nurse) have one hour before potential for actual harm and one after from the scheduled time to give the medications. LVN 1 stated she was informed by the nurse practitioner and/or physician (does not recall exactly who) that if the resident continues to request to receive Residents Affected - Some the medications earlier than the scheduled time then the timing will be changed.

During an interview on 4/11/2025 at 11:26 a.m. with the [NAME], the [NAME] stated Resident 19's medications should be administered at the scheduled time and can be administered one hour before or one hour after the scheduled time. The [NAME] stated LVN 1 should have documented the reason for giving medication early.

During an interview on 4/11/2025 at 1:18 p.m. with the DP, the DP stated their (facility) MARs have a built-in one hour before and one hour after time frames to record medication administration. The DP stated if the medication nurse was unable to sign Resident 19's MAR, they (licensed nurses) would need to check with

the provider (resident's physician) if it is okay to give outside the scheduled time. The DP stated the MAR has specified window of when medications can be given because they do not want to give medications too early or too late. The DP stated she expects the medication nurse (licensed nurse) to notify the provider directly or to let the pharmacy know so they (licensed nurses) can place the order. The DP stated the medication nurse should not give the medication outside of the prescribed time because it is deviating from

the current order. The DP stated all medications administered should be documented on the MAR and reflect

the actual time it was given.

During an interview on 4/11/2025 at 5:17 p.m. with the DLTC, the DLTC stated Resident 19's medications should have been given at the scheduled time. The DLTC stated when medications are not given at the scheduled time the resident may not get the full effect and may have potential drug interactions.The DLTC stated the medication nurse is expected to clarify with the provider regarding the timing of the medication and document the communication with the provider.

During a review of the facility's P&P titled, General Administrative, last reviewed 3/2024, the P&P indicated

the purpose its policy to provide a safe and efficient medication distribution system which shall include the evaluation, selection, purchase, storage, control, dispensing and administration of all drugs, chemicals and pharmaceuticals used throughout the Motion Picture and Television Fund Hospital (MPTF) organization. The P&P indicated that All medications administered to patients must be first ordered by a physician on the MPTF medical staff or an individual who has been granted clinical privileges. Each dose of medication shall be accurately recorded in the patient's medical record.

During a review of the facility's P&P titled, Medication Administration, last reviewed 12/5/2024, the P&P indicated Medication shall be accurately and safely administered to MPTF patients/resident by authorized personnel. The procedure P&P indicated the licensed nurses to Sign the eMAR after administration or non-administration of all medications. The P&P indicated the six (6) Rights of Safe Medication Administration are Right Medication, Right Dose, Right Patient/Resident, Right Route, Right Time, and Right Documentation. The P&P indicated the physician's order must include the date and time of the order, name of medication, dose, frequency, route, indication, duration, if appliable, and diagnosis.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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 3. During a review of Resident 86's FS, the FS indicated the facility admitted Resident 86 on 3/5/2025.

Level of Harm - Minimal harm or During a review of Resident 86's CRA, the CRA indicated Resident 86 had diagnoses including epilepsy (a potential for actual harm condition that affects the brain and causes frequent seizures, muscle spasm (a sudden, involuntary movement in one or more muscles), neuralgia (a sharp, shocking pain that follows the path of a nerve and is Residents Affected - Some due to irritation or damage to the nerve), and neuritis (inflammation of a nerve).

During a review of Resident 86's MDS, dated [DATE REDACTED], the MDS indicated Resident 86 had unclear speech, adequate hearing, rarely/never made self understood, and rarely/never understands others. The MDS indicated Resident 86 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 86 required assistance from staff with ADLs and mobility. The MDS indicated the resident had a feeding tube (a flexible tube inserted into the stomach or intestines to deliver liquid nutrition) while a resident of the facility.

During a review of Resident 86's Orders, the Orders indicated:

- gabapentin 300 mg, give 300 mg (one tablet) via g-tube three times a day, administer through the percutaneous endoscopic gastrostomy (PEG- a procedure for placing a feeding tube directly into the stomach through the abdominal wall, bypassing the mouth and esophagus) tube, indication for neuralgia and neuritis, dated 3/5/2025.

- quetiapine fumarate (Seroquel- drug used to manage abnormal condition of the mind described as involved

a loss of contact with reality) 100 mg, give 100 mg (one tablet) via g-tube three times a day via PEG tube, indications for encephalopathy (a disease that affects the function or structure of the brain) secondary to hypoxic brain injury (low levels of oxygen in the brain causing irreversible damage) m/b agitation, dated 3/6/2025.

- baclofen 10 mg, give 15 mg (1.5 tablets) via g-tube, three times a day, indication for muscle spasticity of cerebral (brain) origin, dated 4/6/2025.

During a review of Resident 86's MAR, for April 2025, the MAR indicated the scheduled time for Resident 86's medications to be given at 2 p.m. included gabapentin, quetiapine, and baclofen.

During a concurrent observation and interview on 4/10/2025 at 1 p.m. with LVN 1, LVN 1 prepared Resident 86's medications: quetiapine 100 mg, one tab; gabapentin 300 mg, one capsule; baclofen 10 mg, 1.5 tablets. LVN 1 stated she will administer three medications, total 3.5 tablets to give. LVN 1 crushed each tablets separately in a plastic pouch and poured separately into each medication cup. Observed LVN 1 poured five to 10 ml of water into each medication cup and stirred the medications.

During an observation on 4/10/2025 at 1:10 p.m. with LVN 1, at Resident 86's bedside, LVN 1 informed Resident 86 that she (LVN 1) prepared the resident's medications to administer. LVN 1 located Resident 86's g-tube and checked g-tube residual (the amount aspirated from the stomach following administration of enteral feed) which was zero (0) ml. LVN 1 flushed Resident 86's g-tube with 30 ml of water by gravity. LVN 1 administered all three medications with no flushing of water in between medications then flushed with 30 ml of water afterwards. LVN 1 stated she had completed medication pass for Resident 86.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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

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

F 0759 During an interview on 4/10/2025 at 1:24 p.m. with LVN 1, LVN 1 stated she prepared Resident 86's medications then she went inside Resident 86's room. LVN 1 stated she checked Resident 86's g-tube Level of Harm - Minimal harm or residual and there was none. LVN 1 stated she flushed the g-tube with 30 ml and gave the medications then potential for actual harm flushed the g-tube another 30 ml afterwards. LVN 1 stated she did not check for patency during the medication pass because in the morning before the night shift nurse left, she (LVN 1) checked Resident 86's Residents Affected - Some g-tube and it was patent. LVN 1 stated she uses a stethoscope to check for patency. LVN 1 stated her supervisor has told her that she did not need to check for patency every medication pass (medication administration). LVN 1 stated she checks for g-tube patency once per day at the beginning of her shift. LVN 1 stated she did not flush the g-tube in between medications because she follows the physician's order which was to flush the g-tube before and after medication administration. LVN 1 stated there was no order to flush

the g-tube in between medications.

During a concurrent interview and record review on 4/10/2025 at 2:15 p.m. with the DLTC, reviewed the facility's policy and procedure (P&P) titled, Tube Feeding Maintenance and Medication Administration, last reviewed 12/5/2024. The DLTC stated the P&P for g-tube medication administration is to check placement, patency, and residual before every scheduled medication administration time. The DLTC stated the P&P indicated #10 administer prepared medication separately (Do not mix medication) and flush with 15 ml to 30 ml (unless otherwise ordered) of water between each med (prevent air from entering the tube and follow feeding procedure). The DLTC stated medication nurses are expected to flush 15 to 30 ml between every medication unless there is an order to administer specific amount of water to flush. The DLTC stated if there is no physician's order; the standard of practice applicable to residents including Resident 86 is to flush 15 ml to 30 ml of water between medications.

During a concurrent interview and record review on 4/10/2025 at 2:47 p.m. with LVN 1, reviewed Resident 86's MAR. LVN 1 stated there was a physician's order to flush Resident 86's g-tube with 30 ml of water

before and after medication administration which she did. LVN 1 stated she did not give water flush in between medications because there was no order to flush in between medications.

During a concurrent interview and record review on 4/10/2025 at 2:55 p.m. with LVN 1, reviewed the facility's P&P titled, Tube Feeding Maintenance and Medication Administration, last reviewed 12/5/2024. LVN 1 stated she did not follow their P&P to flush in between medications and did not check Resident 86's g-tube placement and patency at every scheduled medication administration. LVN 1 stated the [NAME] provided the instructions that there is no need to check for g-tube placement and patency at every scheduled medication administration, and that checking for g-tube placement and patency once at the beginning of the shift or the first scheduled medication during her shift was good.

During an interview on 4/11/2025 at 11:26 a.m. with the [NAME], the [NAME] stated the standard of practice for g-tube administration is to check for placement, patency, residual, flush with water before medication administration, in between medications, and after medication administration. The [NAME] stated she did not provide instruction to LVN 1 to only checking placement and patency at the beginning of the shift during the first scheduled medication. The [NAME] stated their policy is to check for placement, patency, and residual done before administering every scheduled medication to be administered. The [NAME] stated flushing in between medications is done as to not mix the medications. The [NAME] stated when flushing in between medications is not done, then it is the same as mixing the medications in the same cup. The [NAME] stated LVN 1 should have followed their policy when LVN 1 administered medications to Resident 86.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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

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

F 0759 During an interview on 4/11/2025 at 1:18 p.m. with the DP, the DP stated their (facility) MARs have a built-in one hour before and one hour after time frames to record medication administration. The DP stated if the Level of Harm - Minimal harm or medication nurse was unable to sign Resident 19's MAR, they (licensed nurses) would need to check with potential for actual harm the provider (resident's physician) if it is okay to give outside the scheduled time. The DP stated the MAR has specified window of when medications can be given because they do not want to give medications too Residents Affected - Some early or too late. The DP stated she expects the medication nurse (licensed nurse) to notify the provider directly or to let the pharmacy know so they (licensed nurses) can place the order. The DP stated the medication nurse should not give the medication outside of the prescribed time because it is deviating from

the current order. The DP stated all medications administered should be documented on the MAR and reflect

the actual time it was given.

During an interview on 4/11/2025 at 1:25 p.m. with the DP, the DP stated medications given through the g-tube should not be mixed and should be flushed in between medications to maintain g-tube patency and to ensure Resident 86 received the whole dose. The DP stated there is a potential for medication interactions and clogging of the g-tube.

During an interview on 4/11/2025 at 5:17 p.m. with the DLTC, the DLTC stated it is important for the medication nurse to flush in between medications because they would not know what the drug interaction for Resident 86 and this is to ensure the patency of the g-tube and that the resident receives the medications as ordered. The DLTC stated the purpose of checking for patency and placement is to ensure the g-tube is in

the right place. The DLTC stated when this is not done the resident could potentially not receive the medications or the medication could go to a different area of the body and would not be properly absorbed.

During a review of the facility's P&P titled, Tube Feeding Maintenance and Medication Administration, last reviewed 12/5/2024, the P&P indicated the purpose of the policy is to provide medication administration when unable to take orally and to monitor for signs and symptoms of infection, irritation at the stoma (a surgically created opening on the abdomen) site. The P&P indicated procedure for medication administration:

1. Check doctor's order.

2. Wash hands and prepare equipment.

3. Identify patient and explain procedure.

4. Position patient; semi-Fowler's position.

5. [NAME] (put on) gloves and check feeding tube for placement, patency, and residual.

6. For GT/JT placement check: air auscultation (a method used to listen to the sounds of the body by using a stethoscope [medical device), stomach secretions, aspiration .

7. Check gastric residual before giving medication (unless otherwise ordered).

8. If residual is greater than 100 ml, hold medication for one hour and repeat check .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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 9. Flush tube with 30 ml of water prior to administering medication unless physician orders different amount for flush. Level of Harm - Minimal harm or potential for actual harm 10. Administer prepared medication separately (Do not mix medication) and flush with 15 ml to 30 ml (unless otherwise ordered) of water between each med (Prevent air from entering the tube and follow feeding Residents Affected - Some procedure).

11. After medication is administered, instill 30 mls of water to clear the tube or as GNP/ General Nurse Practitioner (GNP)/Physician order indicates.

During a review of the facility's P&P titled, General Administrative, last reviewed 3/2024, the P&P indicated

the purpose its policy to provide a safe and efficient medication distribution system which shall include the evaluation, selection, purchase, storage, control, dispensing and administration of all drugs, chemicals and pharmaceuticals used throughout the Motion Picture and Television Fund Hospital (MPTF) organization.

During a review of the facility's P&P titled, Medication Administration, last reviewed 12/5/2024, the P&P indicated Medication shall be accurately and safely administered to MPTF patients slash resident, by authorized personnel. The P&P indicated the six (6) Rights of Safe Medication Administration are Right Medication, Right Dose, Right Patient/Resident, Right Route, Right Time, and Right Documentation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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** 38552 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure residents were free from Residents Affected - Some significant medications errors for one (1) of 1 sampled resident (Resident 10) reviewed for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) use and for three of five sampled residents (Resident 66, 19, and 86) reviewed under Medication Administration facility task, by:

1. Failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites for Resident 10.

This deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up

in the skin).

2. Failing to ensure Residents 66 and 19's scheduled medications were administered as ordered at the scheduled time.

3. Failing to flush water in between medications for Resident 86 when Licensed Vocational Nurse (LVN) 1 administered the resident's gastrostomy tube (g-tube- a surgical opening fitted with a device to allow feedings to be administered directly to the stomach for people with swallowing problems).

These deficient practices had the potential to result in Resident 86 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and the potential to result in Residents 66 and 19's health and well-being to be negatively impacted.

Cross reference:

F-F761)

Findings:

1. During a review of Resident 39's Face Sheet, the Face Sheet indicated the facility admitted the resident

on 4/18/2018.

During a review of Resident 39's Patient Diagnosis Information, the Patient Diagnosis Information indicated

the resident had diagnoses including neurocognitive disorder with Lewy bodies (a progressive disorder characterized by the gradual decline of thinking and reasoning abilities, often accompanied by movement and sleep disturbances, and visual hallucinations) and PI of the sacral region (lower back at the base of the spine) stage two (partial-thickness loss of skin, presenting as a shallow open sore or wound).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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

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

F 0755 During a review of Resident 39's Minimum Data Set (MDS - resident assessment tool), dated 3/14/2025, the MDS indicated the facility most recently admitted the resident on 8/21/2018. The MDS indicated the resident Level of Harm - Minimal harm or was rarely/never able to understand others and was rarely/never able to make himself understood. The MDS potential for actual harm further indicated the resident was dependent on assistance from staff for eating, toileting, bathing, dressing, personal and oral hygiene, and mobility. Residents Affected - Some

During a review of Resident 39's Care Plan (CP) titled, Pressure Injury Stage Two (2) on sacrum related to previous pressure injury on area, incontinence, impaired mobility, initiated 11/25/2024, the CP indicated a goal that the area would heal without complications in the next 120 days.

During a review of Resident 39's physician orders, the physician orders indicated the following treatment orders:

- Dated 3/26/2025, cleanse PI of the sacrum with wound cleansing spray, gently pat dry, apply maxorb plus silver (an antimicrobial wound dressing), cut to fit wound, cover with opti foam (a type of dressing), change dressing daily.

- Dated 1/30/2025 and discontinued (DC'd) on 2/12/2025, mupirocin 2 percent (% - a unit of measure), apply ointment 1 dose topically twice a day. cleanse PI of the sacrum with warm cleansing wipes, gently pat dry, apply mupirocin ointment prior to application of moisture barrier cream. Indication: stage 2 pressure injury.

During a concurrent observation and interview, on 4/10/2025, at 11:30 a.m., with LVN 1, LVN 1 performed Resident 39's wound care treatment. LVN 1 stated the LVNs provide daily wound care for facility residents. LVN 1 gathered the following wound care supplies from the One [NAME] Treatment Cart: mupirocin ointment placed in a clear medication cup, an opti foam dressing, cleansing spray, and the maxorb dressing. LVN 1 entered Resident 39's room with the supplies, cleansed Resident 39's wound, applied the mupirocin ointment to cover the wound, placed the maxorb dressing on top of the mupirocin ointment, then applied the opti foam dressing. Upon completion of the treatment, LVN 1 exited the resident's room.

During a concurrent interview and record review, on 4/10/2025, at 11:55 a.m., with LVN 1, Resident 39's physician orders were reviewed. LVN 1 stated she applied mupirocin ointment to Resident 39. LVN 1 stated

she always applies the mupirocin when providing Resident 39's wound care treatment. LVN 1 reviewed Resident 39's treatment orders and stated Resident 39 did not have an active order to apply mupirocin. LVN 1 stated prior to administering mupirocin, LVN 1 reviewed Resident 39's treatment order. LVN 1 stated she thought there was an order for mupirocin, but there was not. LVN 1 stated she should have read the order more carefully.

During a concurrent interview and record review, on 4/10/2025, at 12:15 p.m., with Registered Nurse (RN) 3, Resident 39's physician orders were reviewed. RN 3 stated the medication and treatment administration process is to review the physician's treatment orders, remove the medication from the treatment cart, compare the medication with the order, and then apply the medication to the resident. RN 3 stated if there is no order for the mupirocin, the nurse should contact the nurse practitioner or physician to clarify if they would like to continue with the treatment. RN 3 stated there must be a physician's order prior to applying medication to a resident. RN 3 stated Resident 39 did not have an active order for mupirocin when LVN 1 applied the mupirocin to Resident 39. RN 3 stated Resident 39 previously had an order for mupirocin that was discontinued on 2/12/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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

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

F 0755 During a concurrent interview and record review, on 4/10/2025, at 1:13 p.m., with RN 2, Resident 39's physician orders were reviewed. RN 2 stated when a medication is discontinued, the pharmacy and the Level of Harm - Minimal harm or nurse receive a notification to remove the medication from the cart. RN 2 stated Resident 39's mupirocin potential for actual harm order was discontinued on 2/12/2025 and the medication should have been removed immediately from the One [NAME] Treatment Cart to ensure the medication was not administered by mistake. Residents Affected - Some

During an interview, on 4/10/2025, at 2:02 p.m., with LVN 1, LVN 1 stated it is important to carefully review

the treatment order prior to providing the treatment to ensure errors are avoided like administering the wrong medication to the resident. LVN 1 stated Resident 39's discontinued mupirocin ointment remained in the One [NAME] Treatment Cart and LVN 1 administered the discontinued medication to Resident 39 every day that

she worked this week including 4/10/2025, 4/9/2025, 4/8/2025, and 4/7/2025. LVN 1 stated she thought Resident 39 had an order for mupirocin when LVN 1 applied the medication, but there was no order. LVN 1 stated she just saw the mupirocin ointment in the cart, grabbed it, and applied it to Resident 39.

During an interview, on 4/10/2025, at 2:12 p.m., with RN 3, RN 3 stated during medication and treatment administration, nurses should follow the rights of safe medication administration by comparing the physician's order to the actual medication label to ensure the right resident gets the right medication at the right time and no errors are made. RN 3 stated LVN 1 did not follow the rights of safe medication administration, and it resulted in LVN 1 administering a discontinued medication to Resident 39. RN 3 stated when the discontinued mupirocin was administered to Resident 39 there was the potential that the PI healing process would be affected causing a delay in healing or a decline in the resident's condition.

During an interview, on 4/11/2025, at 11:15 a.m., with the Director of Long-Term Care (DLTC), the DLTC stated medications are discontinued for a reason. The DLTC stated discontinued medication may not be an effective treatment, or a different treatment may be more appropriate. The DLTC stated when a discontinued medication was left in the treatment cart and administered to Resident 39, there was a potential that the mupirocin would have a negative effect on the resident's healing process.

During a review of the facility policy and procedure (P&P) titled, Pharmacy: General Administrative, last reviewed 3/2024, the P&P indicated all medications dispensed to residents must be ordered by a prescriber.

A system of controlling nursing medication stock items and replacement is maintained with transaction records to maintain control and accountability of all drugs. All medications administered to residents must be first ordered by a physician or an individual who has been granted clinical privileges. Each dose of medication shall be accurately recorded in the resident's medical record. Residents administered medications shall be carefully monitored to determine whether the medication results in the therapeutically intended benefit, and to allow for early identification of adverse effects and timely initiation of appropriate corrective action.

During a review of the facility P&P titled, Medication Administration, last reviewed 11/2024, the P&P indicated medication shall be accurately and safely administered to residents, by authorized personnel. The procedure includes:

- Access the resident's Medication Administration Record (eMAR) via the Electronic Medical Record (EMR).

a. Compare the label of the unit of medication with the individual resident eMAR.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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

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

F 0755 b. Place medications for individual resident in a small disposable cup, tray or medication cup according to need. Level of Harm - Minimal harm or potential for actual harm c. Identify the resident using two identifiers (never by room number).

Residents Affected - Some d. Assess/monitor a patient/resident who requires checking prior to administering medication, and those for whom PRN/as needed medications have been prescribed. Check for and document effectiveness in the PRN EMR.

e. Remain with the patient/resident until medication has been administered.

f. Discard medication packages and other waste in the mandated receptacles.

g. Sign the eMAR after administration or non-administration of all medications.

- Medication Safety Practices for Medication Administration include:

- The 6 Rights of Safe Medication Administration are:

i. The Right Medication

ii. The Right Dose

iii. The Right Patient/Resident

iv. The Right Route

v. The Right Time

vi. The Right Documentation

- A physician's order must include:

o Date and time of the order

o Name of the medication

o Dose

o Frequency

o Route

o Indication

o Duration, if applicable

o Diagnosis

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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

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

F 0755 38552

Level of Harm - Minimal harm or 2. During a review of Resident 39's Face Sheet (FS- front page of the chart that contains a summary of basic potential for actual harm information about the resident), the Face Sheet indicated the facility admitted the resident on 4/18/2018.

Residents Affected - Some During a record review of Resident 39's Patient Diagnosis Information, the Patient Diagnosis Information indicated the resident had diagnoses that included neurocognitive disorder with Lewy bodies (a progressive disorder characterized by the gradual decline of thinking and reasoning abilities, often accompanied by movement and sleep disturbances, and visual hallucinations) and PI of the sacral region (lower back at the base of the spine) stage two (partial-thickness loss of skin, presenting as a shallow open sore or wound).

During a review of Resident 39's Minimum Data Set (MDS - resident assessment tool) dated 3/14/2025, the MDS indicated the facility most recently admitted the resident on 8/21/2018. The MDS indicated the resident was rarely/never able to understand others and was rarely/never able to make himself understood. The MDS further indicated the resident was dependent on assistance from staff for eating, toileting, bathing, dressing, personal and oral hygiene, and mobility.

During a review of Resident 39's Care Plan (CP) titled, Pressure Injury Stage 2 on sacrum related to previous pressure injury on area, incontinence, impaired mobility, initiated 11/25/2024, the CP indicated a goal that the area would heal without complications in the next 120 days.

During a review of Resident 39's physician orders, the physician orders indicated the following treatment orders:

- Dated 3/26/2025, cleanse PI of the sacrum with wound cleansing spray, gently pat dry, apply maxorb plus silver (an antimicrobial wound dressing), cut to fit wound, cover with opti foam (a type of dressing), change dressing daily.

- Dated 1/30/2025 and discontinued (DC'd) on 2/12/2025, mupirocin 2 %, apply ointment 1 dose topically twice a day. cleanse PI of the sacrum with warm cleansing wipes, gently pat dry, apply mupirocin ointment prior to application of moisture barrier cream. Indication: stage 2 pressure injury.

During a concurrent observation and interview on 4/10/2025 at 11:30 a.m. with LVN 1, observed Resident 39's wound care treatment in the resident's room. LVN 1 stated the LVNs provide daily wound care for facility residents. LVN 1 gathered the following wound care supplies from the One [NAME] Treatment Cart: mupirocin ointment placed in a clear medication cup, an opti foam dressing, cleansing spray, and the maxorb dressing. LVN 1 entered Resident 39's room with the supplies, cleansed Resident 39's wound, applied the mupirocin ointment to cover the wound, placed the maxorb dressing on top of the mupirocin ointment, then applied the opti foam dressing. Upon completion of the treatment, LVN 1 exited the resident's room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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

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

F 0755 During a follow up observation, interview, and record review on 4/10/2025 at 11:55 a.m. with LVN 1, LVN 1 reviewed Resident 39's physician orders. LVN 1 stated LVN 1 applied mupirocin ointment to Resident 39. Level of Harm - Minimal harm or LVN 1 stated LVN 1 always applies the mupirocin when providing Resident 39's wound care treatment. LVN potential for actual harm 1 then reviewed Resident 39's treatment orders and noted Resident 39 did not have an active order to apply mupirocin. LVN 1 stated prior to administering mupirocin, LVN 1 reviewed Resident 39's treatment order. Residents Affected - Some LVN 1 stated LVN 1 thought there was an order for mupirocin, but there was not. LVN 1 stated LVN 1 should have read the order more carefully.

During a concurrent interview and record review on 4/10/2025 at 12:15 p.m. with Registered Nurse (RN) 3, RN 3 reviewed Resident 39's physician orders. RN 3 stated the medication and treatment administration process it to review the physician's treatment orders, remove the medication from the treatment cart, compare the medication with the order, and then apply the medication to the resident. RN 3 stated if there is no order for the mupirocin, the nurse should contact the nurse practitioner or physician to clarify if they would like to continue with the treatment. RN 3 stated there must be a physician's order prior to applying medication to a resident. RN 3 stated Resident 39 did not have an active order for mupirocin when LVN 1 applied the mupirocin to Resident 39. RN 3 stated Resident 39 previously had an order for mupirocin that was discontinued on 2/12/2025.

During a concurrent interview and record review on 4/10/2025 at 1:13 p.m. with RN 2, RN 2 reviewed Resident 39's physician orders. RN 2 stated when a medication is discontinued, the pharmacy and the nurse receive a notification to remove the medication from the cart. RN 2 stated Resident 39's mupirocin order was discontinued on 2/12/2025 and the medication should have been removed immediately from the One [NAME] Treatment Cart to ensure the medication was not administered by mistake.

During an interview on 4/10/2025 at 2:02 p.m. with LVN 1, stated it is important to carefully review the treatment order prior to providing the treatment to ensure errors are avoided like administering the wrong medication to the resident. LVN 1 stated Resident 39's discontinued mupirocin ointment remained in the One [NAME] Treatment Cart and LVN 1 administered the discontinued medication to Resident 39 every day that

she worked this week including 4/10/2025, 4/9/2025, 4/8/2025, and 4/7/2025. LVN 1 stated LVN 1 thought Resident 39 had an order for mupirocin when LVN 1 applied the medication, but there was no order. LVN 1 stated LVN 1 just saw the mupirocin ointment in the cart, grabbed it, and applied it to Resident 39.

During a follow up interview on 4/10/2025 at 2:12 p.m. with RN 3, RN 3 stated during medication and treatment administration nurses should follow the rights of safe medication administration by comparing the physician's order to the actual medication label to ensure the right resident gets the right medication at the right time and no errors are made. RN 3 stated LVN 1 did not follow the rights of safe medication administration, and it resulted in LVN 1 administering a discontinued medication to Resident 39. RN 3 stated when the discontinued mupirocin was administered to Resident 39 there was the potential that the PI healing process would be affected causing a delay in healing or a decline in the resident's condition.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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

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

F 0755 During a concurrent interview and record review on 4/11/2025 at 11:15 a.m. with the Director of Long Term Care (DLTC), the DLTC reviewed the facility policy and procedure regarding medication administration and Level of Harm - Minimal harm or medication storage. The DLTC stated medications are discontinued for a reason. The DLTC stated potential for actual harm discontinued medication may not be an effective treatment, or a different treatment may be more appropriate. The DLTC stated when a discontinued medication was left in the treatment cart and Residents Affected - Some administered to Resident 39, there was a potential that the mupirocin would have a negative effect on the resident's healing process.

A review of the facility policy and procedure (P&P) titled, Pharmacy: General Administrative, last reviewed 3/2024, the P&P indicated all medications dispensed to patients must be ordered by a prescriber. A system of controlling nursing medication stock items and replacement is maintained with transaction records to maintain control and accountability of all drugs. All medications administered to patients must be first ordered by a physician or an individual who has been granted clinical privileges. Each dose of medication shall be accurately recorded in the patient's medical record. Patients administered medications shall be carefully monitored to determine whether the medication results in the therapeutically intended benefit, and to allow for early identification of adverse effects and timely initiation of appropriate corrective action.

A review of the facility policy and procedure (P&P) titled, Medication Administration, last reviewed 11/2024,

the P&P indicated medication shall be accurately and safely administered to residents, by authorized personnel. The procedure includes:

- Access the resident's Medication Administration Record (eMAR) via the Electronic Medical Record (EMR).

a. Compare the label of the unit of medication with the individual resident eMAR.

b. Place medications for individual resident in a small disposable cup, tray or medication cup according to need.

c. Identify the resident using two identifiers (never by room number).

d. Assess/monitor a patient/resident who requires checking prior to administering

e. medication, and those for whom PRN/as needed medications have been prescribed. Check for and document effectiveness in the PRN EMR.

f. Remain with the patient/resident until medication has been administered.

g. Discard medication packages and other waste in the mandated receptacles.

h. Sign the eMAR after administration or non-administration of all medications.

- Medication Safety Practices for Medication Administration include:

- The 6 Rights of Safe Medication Administration are:

i. The Right Medication

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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

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

F 0755 ii. The Right Dose

Level of Harm - Minimal harm or iii. The Right Patient/Resident potential for actual harm iv. The Right Route Residents Affected - Some v. The Right Time

vi. The Right Documentation

- A physician's order must include:

o Date and time of the order

o Name of the medication

o Dose

o Frequency

o Route

o Indication

o Duration, if applicable

o Diagnosis

3. During a review of Resident 66's FS, the FS indicated the facility admitted the resident on 8/18/2023.

During a review of Resident 66's Clinical Record Abstract (CRA), the CRA indicated Resident 66 had diagnoses including dementia (a progressive state of decline in mental abilities), paraplegia (loss of movement and/or sensation, to some degree, of the legs), and seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness).

During a review of Resident 66's MDS, dated [DATE REDACTED], the MDS indicated Resident 66 had adequate hearing, clear speech, had the ability to make self understood, and usually understand others. The MDS indicated Resident 66 required substantial assistance with eating and was dependent on staff on functional abilities in mobility.

During a review of Resident 66's Orders (physician's orders), the Orders indicated:

- carboxymethylcellulose sodium (Refresh Tears-eye drops) 0.5 percent (%-a unit of measurement), take two drops twice a day, indication for irritation or dry eye, dated 9/29/2023.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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

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

F 0755 - cetirizine hydrochloride (HCL) (Zyrtec-antihistamine helps relieve allergies), give 10 milligrams (mg-a unit of measurement), give 10 mg (1 tablet) by mouth daily, indication for pruritus (itching), dated 4/9/2024. Level of Harm - Minimal harm or potential for actual harm - Eyelid cleanser (Ocusoft lid scrub), instill one pad into both eyes, twice a day, indication for blepharitis (inflammation of the eyelid), dated 12/6/2024. Residents Affected - Some - lacosamide (Vimpat-antiseizure medication) give 150 mg, one tablet by mouth, twice a day, indication for seizure disorder, dated 8/31/2023.

- levetiracetam (Keppra- antiseizure) 500 mg, give 750 mg (1.5 tablets) by mouth, twice a day, indication for seizure disorder, dated 2/8/2024.

During a review of Resident 66's Medication Administration Record (MAR-a record of medications administered to residents), for April 2025, the MAR indicated the scheduled time for Resident 66's medications to be given at 9 a.m. included carboxymethylcellulose sodium, cetirizine hydrochloride, eyelid cleanser, lacosamide, and levetiracetam.

During a concurrent observation and interview on 4/10/2025 at 7:27 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 prepared the following medications for Resident 66: lacosamide, one tablet (tab); levetiracetam 500 mg, 1.5 tabs; cetirizine 10 mg, one tab; carboxymethylcellulose eye drops; and eyelid cleanser. LVN 1 stated she has a total of 3.5 tablets and one eye drops to give.

During an observation and interview on 4/10/2025 at 7:31 a.m. with LVN 1, at Resident 66's bedside, LVN 1 administered 3.5 tablets, and one eye drop medications to Resident 66. LVN 1 stated she completed medication administration for Resident 66.

During a concurrent interview and record review on 4/10/2025 at 7:34 a.m. with LVN 1, reviewed Resident 66's MAR for 4/10/2025. LVN 1 stated she cannot sign Resident 66's MAR with the actual time she gave the medications because the system will not allow her until 8 a.m. LVN 1 stated the medications she gave were scheduled at 9 a.m. LVN 1 stated she will continue to pass (administer) medications.

During an interview on 4/10/2025 at 7:45 a.m. with LVN 1, LVN 1 stated she has notified Residents 66's nurse practitioner weeks before (does not recall exact date) with regard to the resident's preference to administer the medications earlier than the scheduled time. LVN 1 stated they (licensed nurses) have one hour before and one after from the scheduled time to give the medications. LVN 1 stated she was informed by the nurse practitioner and/or physician (does not recall exactly who) that if the resident continues to request to receive the medications earlier than the scheduled time then the timing will be changed. LVN 1 stated she gave the medications earlier because when Resident 66 was up in the chair, it was difficult to administer the eye drops compared to when the resident is was still on bed. LVN 1 stated she also asked Resident 66 if he would like to receive his medications before the scheduled time and Resident 66 stated he would like to take his medications if they were ready. LVN 1 stated she gives the medications to Resident 66 outside the scheduled time about three times a week but not all the time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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

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

F 0755 During an interview on 4/11/2025 at 11:26 a.m. with the Employee Health Manager ([NAME]), the [NAME] stated medications should be administered at the scheduled time and can be administered one hour before Level of Harm - Minimal harm or or one hour after the scheduled time. The [NAME] stated LVN 1 should have documented the reason for potential for actual harm giving medication early for Resident 66.

Residents Affected - Some During an interview on 4/11/2025 at 1:18 p.m. with the Director of Pharmacy (DP), the DP stated their MARs have a built-in one hour before and one hour after (time frames to record medication administration). The DP stated if the medication nurse was unable to sign the MAR of Resident 66, they (licensed nurses) would need to check with the provider (resident's physician) if it is okay to give outside the scheduled time. The DP stated the MAR has specified window of when medications can be given because they do not want to give medications too early or too late. The DP stated she expects the medication nurse (licensed nurse) to notify

the provider directly or to let the pharmacy know so they (licensed nurses) can place the order. The DP stated the medication nurse should not give the medication outside of the prescribed time because it is deviating from the current order. The DP stated all medications administered should be documented on the MAR and reflect the actual time it was given.

During an interview on 4/11/2025 at 5:17 p.m. with the Director of Long-Term Care (DLTC), the DLTC stated medications should be given at the scheduled time. The DLTC stated when medications are not given at the scheduled time, Resident 66 may not get the full effect and may have potential drug interactions. The DLTC stated the medication nurse is expected to clarify with the provider regarding the timing of the medication of Resident 66 and document the communication with the provider.

During a review of the facility's P&P titled, General Administrative, last reviewed 3/2024, the P&P indicated

the purpose its policy to provide a safe and efficient medication distribution system which shall include the evaluation, selection, purchase, storage, control, dispensing and administration of all drugs, chemicals and pharmaceuticals used throughout the Motion Picture and Television Fund Hospital (MPTF) organization. The P&P indicated that All medications administered to patients must be first ordered by a physician on the MPTF medical staff or an individual who has been granted clinical privileges. Each dose of medication shall be accurately recorded in the patient's medical record.

During a review of the facility's P&P titled, Medication Administration, last reviewed 12/5/2024, the P&P indicated Medication shall be accurately and safely administered to MPTF patients/resident by authorized personnel. The procedure P&P indicated the licensed nurses to Sign the eMAR after administration or non-administration of all medications. The P&P indicated the six (6) Rights of Safe Medication Administration are Right Medication, Right Dose, Right Patient/Resident, Right Route, Right Time, and Right Documentation. The P&P indicated the physician's order must include the date and time of the order, name of medication, dose, frequency, route, indication, duration, if appliable, and diagnosis.

4. During a review of Resident 19's FS, the FS indicated the facility admitted the resident on 8/7/2024.

During a review of Resident 19's CRA, the CRA indicated Resident 19 had diagnoses including dementia, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and constipation (a problem with passing stool).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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

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

F 0755 During a review of Resident 19's MDS, dated [DATE REDACTED], the MDS indicated Resident 19 had minimal difficulty hearing, clear speech, had the ability to make self understood and understand others. The MDS indicated Level of Harm - Minimal harm or Resident 19 required staff assistance with activities of daily living (ADLs- activities such as bathing, dressing potential for actual harm and toileting a person performs daily) and mobility.

Residents Affected - Some During a review of Resident 19's Orders, the Orders indicated the following:

- donepezil HCL (Aricept-used to treat dementia), give 5 mg, one tablet by mouth daily, indication for dementia, dated 8/7/2024.

- gabapentin (Neurontin- nerve pain medication), give 100 mg, one capsule by mouth, twice a day, indication for depression m/b refusing and resistance to care, dated 12/24/2024.

- metformin extended release (Glucophage Extended Release- medication that helps lower high blood sugar) 500 mg, give 1000 mg (two tablets) by mouth, twice a day, indication for diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), dated 8/7/2024.

- pantoprazole (Protonix- decreases amount of acid produced in the stomach) 40 mg, give 40 mg, one tablet by mouth, daily, indication for gastroesophageal reflux disease (GERD- a condition in which the stomach contents move up into the esophagus), dated 8/7/2024.

- polyethylene glycol 3350 (Miralax- used to treat constipation) 15 grams (g-a unit of measurement)/dose, give 17 g (one powder) by mouth daily, mix with eight (8) ounces (oz- a unit of measurement) of liquid or juice, indication for constipation, dated 8/7/2024.

- solifenacin succinate (Vesicare- used to treat overactive bladder [OAB- a problem with bladder (organ that stores urine before leaving the body) function that causes the sudden need to urinate]) 5 mg, give 5 mg (one tablet) by mouth, daily, indication for OAB, dated 2/21/2025.

During a review of Resident 19's MAR, for April 2025, the MAR indicated the scheduled time for Resident 19's medications to be given at 9 a.m. on 4/10/2025 included donepezil HCL, gabapentin, metformin extended release, pantoprazole, polyethylene glycol 3350, and solifenacin.

During a concurrent observation and interview on 4/10/2025 at 7:37 a.m. with LVN 1, LVN 1 prepared Resident 19's including medications: pantoprazole 40 mg, one tab; metformin 500 mg, two tabs; gabapentin 100 mg, one capsule; solifenacin 5 mg, one tab; donepezil 5 mg, one tab; polyethylene glycol 17 g. LVN 1 stated she will administer a total of eight medications with seven tablets and one powder. LVN 1 stated she will separate buspirone and gabapentin into a separate medication cup because Resident 19 usually does not want to take all the medications.

During a concurrent observation and interview on 4/10/2025 at 7:43 a.m. with LVN 1, at Resident 19's bedside, LVN 1 stated Resident 19 does not want to take all the medications. LVN 1 offered buspirone and gabapentin to Resident 19 which the resident took. LVN 1 offered the rest of the medications but Resident 19 refused.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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

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

F 0755 During a concurrent interview and record review on 4/10/2025 at 7:44 a.m. with LVN 1, reviewed Resident 19's MAR for 4/10/2025. LVN 1 stated she cannot sign at 7:44 a.m. the medications administered because Level of Harm - Minimal harm or the electronic MAR will not save the date and time she gave the medications. LVN 1 stated she will have to potential for actual harm wait until 8 a.m. to sign Resident 19's medications.

Residents Affected - Some During an interview on 4/10/2025 at 7:45 a.m. with LVN 1, LVN 1 stated she has notified Resident 19's nurse practitioner weeks before (does not recall exact date) with regard to the resident's preference to administer

the medications earlier than the scheduled time. LVN 1 stated they (licensed nurse) have one hour before and one after from the scheduled time to give the medications. LVN 1 stated she was informed by the nurse practitioner and/or physician (does not recall exactly who) that if the resident continues to request to receive

the medications earlier than the scheduled time then the timing will be changed.

During an interview on 4/11/2025 at 11:26 a.m. wi [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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

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

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

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44376 potential for actual harm Based on interview and record review, the facility failed to ensure each resident's drug regimen was free Residents Affected - Some from unnecessary drugs by failing to:

1. Ensure the antibiotic medications had monitoring for adverse effect (unwanted undesirable effects that are possibly related to a drug) for two of three sampled residents (Residents 21 and 4) reviewed for antibiotic use.

2. Ensure the antiplatelet (medications that prevent blood clots from forming) had monitoring for adverse effect for one of three sampled residents (Resident 338) reviewed for anticoagulant (a substance that is used to prevent and treat blood clots in blood vessels and the heart) use.

This deficient practice placed the residents at risk for unnecessary medication and undetected adverse/side effects.

Findings:

1. During a review of Resident 21's Face Sheet, the Face Sheet indicated the facility admitted the resident

on 11/30/2023.

During a review of Resident 21's History and Physical (H&P), dated 11/24/2024, the H&P indicated the resident was awake, alert, pleasant, and cooperative. The H&P indicated the resident had dyslipidemia (having too much or too little of certain fats [lipids] in the blood, like cholesterol or triglycerides), chronic recurrent pneumonia (two or more episodes of pneumonia [lung infection] in 12 months or three episodes altogether), and atrial fibrillation (a common heart condition where the heart's upper chambers [atria] beat irregularly, sometimes too fast, creating a quivering or fluttering sensation). The H&P indicated per primary medical doctor (PMD) the resident will continue twice weekly azithromycin (an antibiotic medicine) life-long, and daily prednisone (a corticosteroid medicine used to decrease inflammation).

During a review of Resident 21's Minimum Data Set (MDS, a resident assessment tool), dated 2/14/2025,

the MDS indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment (having noticeable difficulties with thinking and memory that start to impact daily life). The MDS indicated the resident was on a high-risk drug class antibiotic.

During a review of Resident 21's Active Orders, dated 11/25/2024, the Active Orders indicated an order for azithromycin (Zithromax) 250 milligrams (mg - a unit of measure for mass). Give 250 mg (one [1] tablets) by mouth Monday and Friday per prescriber. Indication: pneumonia prophylaxis (measures taken to prevent pneumonia, a lung infection). The orders did not indicate an order for monitoring for adverse/side effects on

the use of azithromycin.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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

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

F 0757 During a concurrent interview and record review, on 4/10/2025, at 9:07 a.m., with Registered Nurse (RN) 2, Resident 21's Active Orders, Medication Administration Record (MAR), and Care Plan were reviewed. RN 2 Level of Harm - Minimal harm or stated there was no order for monitoring for adverse effects of the medication azithromycin as prophylaxis for potential for actual harm pneumonia on Resident 21. RN 2 stated it was important for Resident 21 to have a monitoring for the adverse effect on the use of antibiotic to intervene when a complication arises and to prevent antibiotic Residents Affected - Some resistance (occurs when bacteria develop defenses against the antibiotics designed to kill them).

During an interview, on 4/10/2025, at 2:55 p.m., with the Director of Pharmacy (DP), the DP stated there should be monitoring for adverse effect on the use of azithromycin for pneumonia prophylaxis to ensure its safe use. The DP stated it is a standard of practice to monitor the adverse effect of antibiotic medication administration on residents.

During an interview, on 4/11/2025, at 3:23 p.m., with the Director of Long-Term Care (DLTC), the DLTC stated the staff should have obtained an order from the physician for monitoring of adverse effects on the use of Resident 21's antibiotic azithromycin. The DLTC stated it is important for Resident 21 to be monitored for adverse effect on the use of antibiotic to mitigate the negative reaction of the medication in a timely manner.

During a review of the facility-provided Summary of Product Characteristics of Azithromycin dihydrate 200 mg/5 milliliters (ml - a unit of measure for volume) Powder for Oral Suspension, dated 5/2024, the Summary of Product Characteristics indicated for treatment of upper and lower respiratory tract infections, skin and soft tissues infections and odontostomatological (referring to the field of study and practice related to teeth, their structure, and diseases) infections 500 mg per day taken once daily, for 3 consecutive days. The same dosage regimen can be applied to elderly patients. Since elderly patients are more susceptible to developing cardiac arrythmia, particular caution is recommended due to the risk of developing cardiac arrhythmia (a problem with the rate or rhythm of the heartbeat) and torsade de pointes (a type of very fast heart rhythm [tachycardia] that starts in your heart's lower chambers [ventricles]).

2. During a review of Resident 4's Face Sheet, the Face Sheet indicated the facility admitted the resident on 12/8/2022.

During a review of Resident 4's H&P, dated 9/23/2024, the H&P indicated the resident was awake, alert, coherent, oriented to place, time, and person. The H&P indicated the resident had periprosthetic fracture (a broken bone that occurs near a metal implant, often a joint replacement) of the right femur (the long bone in

the upper leg, also known as the thigh bone), heart failure (a lifelong condition in which the heart muscle cannot pump enough blood to meet the body's needs for blood and oxygen), and chronic kidney disease (long-term condition where the kidneys do not work as well as they should).

During a review of Resident 4's MDS, dated [DATE REDACTED], the MDS indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment. The MDS indicated the resident was on a high-risk drug class antibiotic.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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

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

F 0757 During a review of Resident 4's Active Orders, dated 9/17/2024, the Active Orders indicated amoxicillin (Amoxil) 500 mg. Give 2000 mg (four [4] capsules) by mouth as needed (PRN). Administer two hours prior to Level of Harm - Minimal harm or the scheduled dental procedure. Indication: prophylaxis (measures designed to preserve health) for dental potential for actual harm procedures etc. The Active Orders did not indicate an order for monitoring for adverse/side effects on the use of amoxicillin. Residents Affected - Some

During a concurrent interview and record review, on 4/10/2025, at 10:24 a.m., with RN 2, Resident 4's Active orders, MAR, and Care Plan were reviewed. RN 4 stated there was no monitoring for adverse effect on the use of amoxicillin on the resident. RN 4 stated the amoxicillin was given only once last year. RN 4 stated the order can just be made as a one-time order as opposed to having the order as PRN. RN 4 stated placing the order as PRN increases the risk of staff administering the medication for other indications increasing the risk of medication error. RN 4 stated not monitoring for adverse effect on the use of amoxicillin predisposes Resident 4 to its adverse effect.

During an interview, on 4/10/2025, at 1:20 p.m., with Nurse Practitioner (NP) 1, NP 1 stated the antibiotic amoxicillin for Resident 4 should have been written as a one-time order as opposed to PRN to reduce the risk of medication error of nurse administering the medication for other indication. NP 1 also stated there should be monitoring for adverse effect on the use of amoxicillin to mitigate possible side effects of the medication.

During an interview, on 4/10/2025, at 2:55 p.m., with the DP, the DP stated there should be monitoring for adverse effect on the use of amoxicillin for dental prophylaxis to ensure its safe use. The DP stated it is a standard of practice to monitor for adverse effect of antibiotic medication administration.

During an interview, on 4/11/2025, at 3:23 p.m., with the DLTC, the DLTC stated the amoxicillin order of Resident 4 should have a monitoring for adverse effect to ensure the safe use of the drug and to timely mitigate the negative effects of the medication. The DLTC also stated the order should have been written as

a one-time order instead of a PRN to prevent medication error.

During a review of the facility-provided Highlights of Prescribing Information on the use of Amoxil (amoxicillin) capsules, tablets, or powder for oral suspension, with initial U.S. approval in 1974, the Highlights of Prescribing Information indicated an adverse reaction of Amoxil, capsules, tablets, or oral suspension were diarrhea, rash, vomiting, and nausea. Prescribing Amoxil in the absence of a proven strongly suspected bacterial infection is unlikely to provide benefit to the patient an increase the risk of the development of drug-resistant bacteria.

3. During a review of Resident 338's Face Sheet, the Face Sheet indicated the facility admitted the resident

on 12/20/2024.

During a review of Resident 338's H&P, dated 12/21/2024, the H&P indicated the resident was difficult to communicate with, alert, crying at times, sometimes calm and quiet. The H&P indicated the resident had multi-infarct state (someone has experienced several small strokes, often called mini-strokes or silent strokes, which cause damage to different parts of the brain) with cognitive deficits (a problem with a person's ability to think, learn, remember, and make decisions), hypertension (HTN - a condition where the force of blood pushing against your artery walls is consistently too high) and chronic neuropathic pain (nerve pain that can happen if your nervous system malfunctions or gets damaged).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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

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

F 0757 During a review of Resident 338's MDS, dated [DATE REDACTED], the MDS indicated the resident sometimes make self-understood and usually understand others and had impaired cognition (difficulty with thinking and Level of Harm - Minimal harm or memory functions, including remembering things, concentrating, and making decisions). The MDS indicated potential for actual harm the resident was on a high-risk drug class antiplatelet.

Residents Affected - Some During a review of Resident 338's Active Orders, dated 3/29/2025, the Active Orders indicated an order for aspirin (medication used to prevent blood clots) 81 mg. Give 81 mg (1 tablet) by mouth daily. Indication: cerebrovascular accident (CVA, also known as a stroke, medical emergency that occurs when the blood supply to the brain is interrupted, either by a blockage or a rupture of a blood vessel) prophylaxis and clopidogrel bisulfate (also known as Plavix, medication used to prevent blood clots) 75 mg. Give 75 mg (1 tablet(s)) by mouth daily. Indication: CVA prophylaxis.

During a concurrent interview and record review, on 4/10/2025, at 9:58 a.m., with RN 2, Resident 338's Active Orders, MAR, and Care Plan were reviewed. RN 2 stated there was no order for monitoring of adverse effect on the use of aspirin and Plavix on Resident 338. RN 2 stated it was important to monitor for Resident 338's use of aspirin and Plavix's adverse effect to prevent undue bleeding on the resident.

During an interview, on 4/11/2025, at 3:23 p.m., with the DLTC, the DLTC stated the staff should have monitored for adverse effect on the use of ASA and Plavix on Resident 338 to intervene timely to its adverse effect and prevent bleeding.

During a review of the facility-provided Professional Information on the use of [NAME] Aspirin Tablets, last revised on 4/19/2013, the Professional Information indicated side effects of hemorrhage (an acute loss of blood from a damaged blood vessel), hypersensitivity, anaphylactic shock (a sudden, severe and life-threatening allergic reaction that involves the whole body), rash , urticaria (the medical term for hives), dizziness, and tinnitus (when a person experiences ringing or other noises in one or both of the ears).

During a review of the facility-provided Highlights of Prescribing Information on the use of Plavix (clopidogrel tablets) for oral use, with initial approval in 1997, the Highlights of Prescribing Information indicated adverse reactions such as bleeding, including life-threatening and fatal bleeding, is the most commonly reported adverse reaction.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 92 055034 Department of Health & Human Services Printed: 08/29/2025 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 055034 B. Wing 04/11/2025

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

Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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 - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38552 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure that its medication error rate Residents Affected - Some was less than five percent, when seven (7) medication errors out of 28 opportunities contributed to an overall medication error rate of 25%. The medication error rate are as follows:

1. For Residents 66 and 19, Licensed Vocational Nurse (LVN) 1 failed to administer 9 a.m. scheduled medications at the scheduled time.

2. For Resident 86, LVN 1 failed to flush the resident's gastrostomy tube (g-tube- a surgical opening fitted with a device to allow feedings to be administered directly to the stomach for people with swallowing problems) with water in between medications when LVN 1 administered the resident's g-tube medications.

These deficient practices had the potential to result in Resident 86 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and the potential to result in Residents 66 and 19's health and well-being to be negatively impacted.

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