Health inspection·July 26, 2024

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to assess for cellulitis (when bacteria enter through a crack in the skin and causes skin to become infected and may appear red, warm, and painful to the touch) in the left lower extremity (left leg) in one of three sampled residents, Resident 1. Residents Affected - Some This deficient practice caused Resident 1 to sign out against medical advice (AMA-when a patient leaves a hospital or facility before the treating physician recommends discharge) and go the general acute care hospital (GACH) where Resident 1 was diagnosed with cellulitis of the lower extremity unspecified laterality, bilateral leg pain and at risk for bacteremia (blood stream infection). Resident 1 was given Daptomycin (antibiotic medication used to treat infection) 350 mg (milligram-unit of measurement) IV (intravenous- given through the veins) and subsequently required in-patient admission for continued antibiotic treatment. Findings: A review of Resident 1's admission Record indicated the facility admitted Resident 1 on 7/1/2024 with diagnoses including fusion of spine cervical region (the cartilage in between bones of the neck is removed allowing the bones to fuse together), intervertebral disc degeneration lumbar region, spinal stenosis (narrowing of the hole the spinal cord passes through), diabetes mellitus (DM- long term disease causing high blood sugar), asthma, hypertension (HTN- high blood pressure) and dysphagia (difficulty swallowing. A review of Resident 1's Minimum Data Set (MDS-a standardized assessment and care planning tool) dated 7/13/2024, indicated Resident 1's cognition (mental ability to make decisions for daily living) was intact. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) with toileting, personal hygiene, and transfers (moving between surfaces) from bed to chair. A review of Resident 1's physician order dated 7/11/2024 indicated an order for duplex doppler (an ultrasound test that examines the blood flow in the major arteries and veins in the legs) of right lower extremity (RLE) for swelling. A review of Resident 1's right lower extremity arterial doppler dated 7/13/2024 indicated, mild right lower extremity arterial disease, there is no deep vein thrombosis (DVT- blood clot in vein). A review of Resident 1's GACH History of Present Illness (HPI- a chronological description of the progression of the patient's present illness from the first sign and symptom to the present written by the examining physician) note dated 7/13/2024 indicated Resident 1 had recurrent cellulitis, Page 1 of 5 055136 055136 07/26/2024 Berkley West Healthcare Center 1623 Arizona Avenue Santa Monica, CA 90404

F 0641 presented with bilateral leg swelling and signed out AMA from facility due to not being checked for cellulitis. Level of Harm - Minimal harm or potential for actual harm A review of Resident 1's GACH POC US Soft Tissue (ultrasound of leg done at bedside) of the right extremity dated 7/13/2024 indicated redness and cellulitis with no abscess (a confined pocket of infectious drainage). Residents Affected - Some A review of Resident 1's GACH Emergency Department (ED) Summary dated 7/13/2024, indicated, overall [Resident 1] with redness, warmth anterior portion of legs bilaterally, bedside US done consistent with cobble stoning (a three-dimensional visual appearance of multiple, equally sized, round, raised lesions, resembling roads paved by multiple equal-sized cobbled stones which indicates inflamed tissue)- cellulitis. Discussed with pharmacy about the plan for antibiotics. On 7/24/2024 the California Department of Public Health (CDPH) received a complaint alleging that Resident 1 noted left leg had become redder and more swollen and Resident 1 was concerned about recurrent cellulitis. Resident 1 informed the facility, and an ultrasound on the right leg was ordered. The complaint further alleged Resident 1 requested to see a physician and was told by a facility staff that Resident 1 would have to wait until Monday so Resident 1 decided to sign out AMA and go to the GACH for further evaluation. During a concurrent interview and record review on 7/26/2024 at 11:01 a.m. with the Licensed Vocational Nurse 1 (LVN 1), Resident 1's Nursing progress note dated 7/13/2024 was reviewed. The nursing progress note indicated that on 7/13/2024 at 11 a.m., Resident 1 expressed concern about the redness in Resident 1's LLE and suspected the beginnings of cellulitis. Resident 1 was increased edema (swelling) in both legs, was offered Lasix but refused. On 7/13/2024 at 1 p.m. Resident 1 was still concerned about the resident's leg possibly being infected and was considering going to the GACH. On 7/13/2024 at 3:30 p.m. Resident 1 told LVN 1 that Resident 1wanted to go the GACH to have the LLE examined and did not want to wait for the duplex ultrasound results. LVN 1 stated the doppler ultrasound of the LLE was not ordered nor done. During a concurrent interview and record review on 7/26/2024 at 11:01 a.m. with LVN 1, Resident 1's Situation Background Assessment and Recommendation (SBAR a form used to communicate between the nursing team and the physician) dated 7/13/2024 was reviewed. Resident 1's SBAR indicated Resident 1 complained of redness to the left lower extremity (LLE) and a duplex doppler had been taken that morning, but no results were available. The SBAR form indicated LVN 1 notified the attending physician who ordered a venous doppler of the LLE to be done the previous day and Lasix (a medication that relives the body of fluid buildup) however Resident 1 refused the medication. The SBAR form indicated Resident 1 contacted the resident's own physician and decided to sign out AMA because the resident's left leg was showing early signs of cellulitis. LVN 1 confirmed and stated Resident 1 had swelling and redness on the right leg the day before (7/12/2024) and that is why the US of the right leg was ordered. LVN 1 stated the US took a while to get it done. LVN 1 further stated the US of the RLE was not done until the morning of 7/13/2024 when Resident 1 complained about the LLE. LVN 1 stated Resident 1 left the facility before the US result for the RLE was obtained and before the US of the LLE could be ordered. LVN 1 stated, I should have asked for an US of both legs when the right leg was ordered that is why [Resident 1] called her own doctor and left. During a concurrent interview and record review on 7/26/2024 at 1 p.m., with the Director of Nursing (DON), Resident 1's SBAR dated 7/13/2024 was reviewed. Resident 1's SBAR indicated Resident 1 complained of redness to the left lower extremity (LLE) and a duplex doppler had been taken that 055136 Page 2 of 5 055136 07/26/2024 Berkley West Healthcare Center 1623 Arizona Avenue Santa Monica, CA 90404

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some morning, but no results were available. The SBAR form indicated LVN 1 notified the attending physician who ordered a venous doppler of the LLE to be done the previous day and Lasix (a medication that relives the body of fluid buildup) however Resident 1 refused the medication. Lastly, the form indicated Resident 1 contacted her own physician and decided to sign out AMA because the left leg was showing early signs of cellulitis. The DON stated, if Resident 1 complained about the left leg, then it should have been assessed and reported to the physician so the US could be ordered for the left leg. The DON further stated, I do not see an assessment of either leg documented. During a concurrent interview and record review on 7/26/2024 at 1:15 p.m. with the DON, Resident 1's nursing progress notes dated 7/11/2024, 7/12/2024, 7/13/2024 and the medical records were reviewed. Resident 1's nursing progress notes dated 7/11/2024 -7/13/2024 did not indicate any assessments for the RLE nor the LLE. Resident 1's medical record did not indicate an any SBAR related to RLE redness nor monitoring or RLE nor LLE redness or swelling. The DON stated when there is a change in condition (COCclinically important deviation from a patient's. baseline in physical, cognitive, behavioral, or functional domains) the resident should be assessed, and findings should be communicated to the physician. The DON stated if the physician gives orders, the orders should be carried out and the resident should be monitored for any further changes. A review of the facility's policy and procedures titled, Change in a Resident's Condition or Status, (n.d.) indicated, 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): a. accident or incident involving the resident. b. discovery of injuries of an unknown source. c. adverse reaction to medication. d. significant change in the resident's physical/emotional/mental condition. e. need to alter the resident's medical treatment significantly. f. refusal of treatment or medications two (2) or more consecutive times). g. need to transfer the resident to a hospital/treatment center. h. discharge without proper medical authority; and/or i. specific instruction to notify the Physician of changes in the resident's condition. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting). b. Impacts more than one area of the president's health status. c. Requires interdisciplinary review and/or revision to the care plan; and 055136 Page 3 of 5 055136 07/26/2024 Berkley West Healthcare Center 1623 Arizona Avenue Santa Monica, CA 90404

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some d. Ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. 3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. The resident is involved in any accident or incident that results in an injury including injuries of an unknown source. b. There is a significant change in the resident's physical, mental, or psychosocial status. c. There is a need to change the resident's room assignment. d. A decision has been made to discharge the resident from the facility; and/or e. It is necessary to transfer the resident to a hospital/treatment center. 5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. 6. Regardless of the resident's current mental or physical condition, a nurse or healthcare provider will inform the resident of any changes in his/her medical care or nursing treatments. 7. In addition to notifying the resident and/or representative, the state mental health agency or state intellectual disability agency will be notified within 24 hours of a significant change in the mental or physical condition of a resident with a mental disorder or intellectual disability. 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. 9. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA regulations governing resident assessments and as outlined in the MOS RAI Instruction Manual. The business office manager or designee will verify the address and telephone number of the resident's family or representative (sponsor) on a quarterly basis. Any noted changes will be reported to the Director of Nursing Services to ensure that such information is changed in the resident's medical record. 11. A representative of the business office will notify the resident, his/her family, or representative (sponsor), when: a. There is a change in the resident's billing. b. There is a change in the resident's level of care status. 055136 Page 4 of 5 055136 07/26/2024 Berkley West Healthcare Center 1623 Arizona Avenue Santa Monica, CA 90404

F 0641 c. There is a change in resident rights under federal or state law or regulations; and/or Level of Harm - Minimal harm or potential for actual harm d. There is a change in the rules of the facility that affects the rights or responsibilities of the resident. Residents Affected - Some 055136 Page 5 of 5