Health inspection·December 22, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to: Residents Affected - Some 1. Notify Resident 1's physician of the presence of a severe drug-to-drug interaction warning between Amiodarone and Metoprolol Succinate ER on [DATE]. The facility continued to administer amiodarone and metoprolol Succinate ER despite the presence of negative side effects listed in the severe drug to drug warning (bradycardia and hypotension) from 10/24/24 to 12/9/24. 2. Notify Resident 1's physician of the need to hold medication's frequently due to low blood pressure readings or below the parameter ordered between November 2024 and 12/8/24. 3. Notify Resident 1's physician when medications: metoprolol (Medication to treat/control high blood pressure), spironolactone (Medication to treat/control high blood pressure), and Entresto (Medication for heart failure) were administered even below the ordered parameters. These deficient practices placed Resident 1 at continued risk from potential negative effects of severe drug to drug interactions between amiodarone and metoprolol succinate ER (bradycardia, hypotension, and cardiac arrest) from 10/24/24 to 12/9/24 and the risk for severe hypotension due to the unsafe administration of antihypertensive mediations on 11/28/24 and 11/29/24. Cross Reference:F624, F757, F760, F842 Findings: A review of Resident 1's admission Record, indicated the facility admitted the resident on 10/24/24, with diagnosis that included acute (sudden) on chronic (long-term) systolic cardiac heart failure (a specific type of heart failure that occurs in the heart's left ventricle), paroxysmal A-Fib (fast and irregular heartbeat), essential hypertension (HTN: high blood pressure that is not due to another medical condition), ST-elevation myocardial infarction (STEMI, type of heart attack that is more serious and has a greater risk of serious complications and death) involving coronary artery of anterior wall (the artery supplies blood to the front portion of your heart), sick sinus syndrome (a disease in which the heart's natural pacemaker located in the upper right heart chamber (right atrium) becomes damaged and is no longer able to generate normal heartbeats at the normal rate), rheumatic disorders of both mitral valves (lies between the left atria and the left ventricle) and tricuspid valves (lies between the right atrium and the right ventricle). A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 10/24/24, Page 1 of 32 055136 055136 12/22/2024 Berkley West Healthcare Center 1623 Arizona Avenue Santa Monica, CA 90404

F 0580 Level of Harm - Minimal harm or potential for actual harm indicated the resident had moderately impaired cognition (ability to think, read, learn, remember, reason, express thoughts, and make decisions). The MDS indicated the resident was dependent on staff for toileting, lower body dressing, and putting on and taking off footwear. The MDS indicated the resident required substantial/maximal assistance (helper does more than half the effort) with showering/bathing, upper body dressing, and personal hygiene. Residents Affected - Some A review of Resident 1's Order Summary Report dated 10/24/2024, indicated Resident 1 was on the following medications: a. Amiodarone HCI Oral tablet 200 mg give one tablet by mouth one time a day for A-fib. b. Metoprolol Succinate Extended Release (ER) Oral Tablet 24 Hour 50 mg give one tablet by mouth one time a day for HTN hold for SBP <100 and HR<60. c. Spironolactone Oral tablet 25 mg give 0.5 tablet by mouth one time a day for CHF hold for SBP <100. d. Entresto Oral tablet 24-26mg give 0.5mg by mouth two times a day for HTN for SBP <100. A review of Resident 1's Progress Notes for 10/2024, indicated medication administration orders had triggered a severe drug to drug interaction between Metoprolol Succinate ER and Amiodarone HCL on 10/24/2024 at 8:37 PM, 10/27/2024 at 10:29 AM, 10/30/2024 at 2:38 PM, and 10/30/2024 at 4:08 PM. The progress notes indicated Interaction: Administration of Amiodarone HCI Oral Tablet 200 mg and Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 100 mg may result in severe bradycardia, hypotension and cardiac arrest. The progress notes did not indicate a physician was notified of the severe drug to drug interaction on any of the aforementioned dates. A review of Resident 1's Progress Notes dated 11/28/24 at 8:45 PM, indicated a medication administration order had triggered a severe drug to drug interaction between Metoprolol Succinate ER and Amiodarone HCL. The progress notes indicated Interaction: Administration of Amiodarone HCI Oral Tablet 200 MG and Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 100 MG may result in severe bradycardia, hypotension and cardiac arrest. The note did not indicate the physician was notified of the severe drug to drug interaction. A review of Resident 1's medication administration record (MAR) for November 2024, indicated Metoprolol Succinate ER Oral Tab ER 1 tab one time day (9 AM) for HTN hold for SBP <100 and HR<60 administration was as follows: 11/3: dose held, BP 94/58, 87 11/4: dose held, BP not indicated in MAR, pulse not indicated in MAR (no vital signs documented in medical record) 11/5: dose held, BP 94/58, pulse 85 11/6: dose held, BP 98/65, pulse 81 11/7: dose held, BP not indicated, pulse not indicated (no vital signs documented in medical record) 055136 Page 2 of 32 055136 12/22/2024 Berkley West Healthcare Center 1623 Arizona Avenue Santa Monica, CA 90404

F 0580 11/9: dose held, BP 90/56, pulse 79 Level of Harm - Minimal harm or potential for actual harm 11/10: dose held, BP 90/55, pulse 85 11/12: dose held, BP 90/60, pulse 75 Residents Affected - Some 11/13: dose held, BP not indicated, pulse not indicated (no vital signs documented in medical record) 11/14: dose held, BP 95/55, pulse 86 11/15: dose held, BP 90/60 (taken at 11:02 AM), pulse 80 11/16: dose held, BP 95/60 (taken at 12:17 PM), pulse 80 11/17: dose held, BP 90/60, pulse 71 11/18: dose held, BP 97/65, pulse 76 11/19: dose held, BP not indicated, pulse not indicated (no vital signs documented in medical record) 11/20: dose held, BP not indicated, pulse not indicated (no vital signs documented in medical record) 11/22: dose held, BP 92/61 (taken at 11:18 AM), pulse 74 11/23: dose held, BP 99/64, pulse 80 11/24: dose administered, BP 93/66 (parameter indicated hold for SBP <100), pulse 66 11/25: dose held, BP not indicated on MAR, pulse not indicated on MAR 11/26: dose held, BP not indicated, pulse not indicated (no vital signs documented in medical record) 11/27: dose held, BP 99/65, pulse 76 11/28: dose administered, BP 90/60 (parameter indicated hold for SBP <100), pulse 74 11/29: dose administered, BP 99/67 (parameter indicated hold for SBP <100), pulse 71 11/30: dose held, BP 99/70, pulse 63 A review of Resident 1's MAR for December 2024, indicated Metoprolol Succinate ER Oral Tab ER 1 tab one time day for HTN hold for SBP <100 and HR<60 administration was as follows: 12/1: dose held, BP not indicated, pulse not indicated (no vital signs documented in medical record) 055136 Page 3 of 32 055136 12/22/2024 Berkley West Healthcare Center 1623 Arizona Avenue Santa Monica, CA 90404

F 0580 12/2: dose held, BP 98/59, pulse 83 Level of Harm - Minimal harm or potential for actual harm 12/4: dose held, BP 96/62, pulse 68 12/7: dose held, BP not indicated, pulse not indicated (no vital signs documented in medical record) Residents Affected - Some 12/8: dose held, BP not indicated, pulse not indicated (no vital signs documented in medical record) During an interview on 12/17/24 at 1:27 PM, the Director of Staff Development DSD stated a resident's physician must be informed of three consecutive low BP readings. DSD stated the EHR alerts the nurses of any drug-to-drug interactions. DSD defined drug to drug interactions as two drugs (medications) given together that can cause harm and can increase the likelihood of harm. DSD stated the RNS oversee and act on drug to drug to interactions. DSD stated when the EHR alerts facility staff of severe drug to drug interactions, staff must take immediate action and must contact/notify the resident's physician. During an interview on 12/19/24 at 10:48 AM, License Vocational Nurse (LVN1) stated registered nurse supervisors (RNS) are responsible for inputting medication orders and acting upon severe drug to drug interaction warnings. LVN1 stated the physician must be notified immediately of all severe drug to drug interaction warnings. LVN1 stated physician must be notified of all changes in condition in resident status and VS taken at the time of the change of condition otherwise the residents could receive the wrong treatment. During an interview on 12/19/24 at 11:54 am, the Director of Nursing (DON) stated drug to drug interactions are first reviewed by the facility's contracted pharmacy and then the pharmacy notifies the facility. The DON stated after the pharmacy notifies the facility, the facility contacts the resident the resident's physician to check if it is okay for the resident to receive medications (Spironolactone, Amiodarone, Entresto, and Metoprolol) together. The DON stated the facility must notify a resident's physicians of drug to drug-to-drug interactions immediately, regardless of if the drug-to-drug interactions indicates mild or severe. During a telephone interview on 12/19/2024 at 12:07 PM, the pharmacy consultant (PC) stated there is no system in place that triggered drug-to-drug interaction warnings (warnings advising that certain combinations of medications can cause serious even deadly side effects) on the consultants ends in the EHR. The PC stated the nurses administering the medications are responsible to adhere to the parameters set by the physician and if the medications are being held multiple days the nurses should have notified the physician of the continued need to hold the medications. The PC stated the nurses administering the medications are responsible for notifying the physician if the vital signs are continuously out of the parameters. The PC stated the nurses are holding medications (amiodarone, metoprolol, spironolactone, Entresto) for a reason. During a follow up interview and record review of drug-to-drug interaction alerts on 12/19/24 at 3:15 PM, LVN1 stated, drug-to-drug interactions only appears when a medication is newly ordered. LVN1 stated when a medication is ordered and there is a drug-to-drug interaction present, the RN supervisor is responsible for calling the physician, to clear the drug-to-drug interaction on the MAR/EHR and the medication can be placed on the MAR after the drug-to-drug interaction has been cleared. LVN2 opened up a MAR for another unidentified resident to show the symbol/warning on the MAR that 055136 Page 4 of 32 055136 12/22/2024 Berkley West Healthcare Center 1623 Arizona Avenue Santa Monica, CA 90404

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some signified a drug-to-drug interaction and a symbol with 2 capsules was noted. LVN1 stated the symbol with the 2 capsules indicated drug to drug interactions between medications. LVN1 hovered over the symbol and when LVN1 clicked the legend for the symbol, the legend indicated there were 2 medications that had drug to drug interactions with each other. LVN1 stated she does not need to check what the drug-to-drug interactions were because she (LVN1) assumes the drug-to-drug interactions were already cleared by the RNS. During an interview on 12/20/24 at 11:32 AM, LVN2 stated that drug-to-drug interaction warnings often appear for the first time when a new medication is ordered on the MAR or when a new resident is admitted to the facility. LVN2 stated when she (LVN2) reads the drug-to-drug interaction alert, she takes no action and continues with the medication pass as she assumes that the licensed nurse who had initially placed the order had cleared it. LVN2 admitted that drug-to-drug interactions flagged graded as severe must have immediate action taken which included notifying the physician. LVN2 admitted and stated that Resident 1's BPs were on the lower side almost every single day with and recalled a reading of the SBP 87mmHG. LVN2 stated that she had to hold resident 1's medications often because the parameters were to hold if SBP is less than 100mmHG. On 11/28/2024, Resident 1's SBP was 90/60. LVN2 admitted to administering the following medications: Metoprolol 50 mg (Hold if SBP less [<] than 100mmHG) Entresto oral tabs 24-26mg (hold SBP < 100) Spironolactone oral tab (hold SBP < 100) On 11/29/2024, Resident 1's SBP was 99/67. LVN2 admitted to administering the following medications: Metoprolol 50 mg (Hold if SBP less [<] than 100mmHG) Entresto oral tabs 24-26mg (hold SBP < 100) Spironolactone oral tab (hold SBP < 100) LVN2 confirmed that the above medications should have been held because they were under the ordered parameters. LVN2 admitted that the physician was not notified. During a follow up interview on 12/20/2024 at 1:50 PM, LVN1 stated she (LVN1) was not aware of any drug-to-drug interactions between Resident 1's BP medications (Amiodarone and metoprolol). LVN 1 recalled and admitted that she (LVN1) held BP medications because of the resident's BPs were trending low. LVN1 stated that there was no documented evidence that Resident 1's VS were checked/recorded. LVN1 admitted and stated that she held the aforementioned medications and did not get Resident 1's VS. LVN1 stated that she did not inform a physician that Resident 1's afore mentioned medications were being held more than they were being administered. LVN1 stated that on 12/9/2024 at 1:20 PM, Resident 1 was placed in a wheelchair; was assisted into the facility provided non-emergency transportation vehicle, and then the resident was transported while sitting in the wheelchair to the ALF. LVN1 admitted and stated that she (LVN1) did not recheck Resident 1's VS. During the same interview and concurrent record review on 12/20/2024 at 1:50 PM, Resident 1's MAR for 11/2024 and 12/2024 were reviewed. LVN1 admitted and stated that she administered the following 055136 Page 5 of 32 055136 12/22/2024 Berkley West Healthcare Center 1623 Arizona Avenue Santa Monica, CA 90404

F 0580 medication doses with below acceptable parameters: Level of Harm - Minimal harm or potential for actual harm a) Metoprolol dose administered when BP was below acceptable parameters (SBP<100mmHg) on 11/24/2024, 11/28/2024, and 11/29/2024. Residents Affected - Some b) Spironolactone dose administered when BP was below acceptable parameters (SBP<100mmHg) on 11/17/2024, 11/24/2024, and 11/30/2024. c) Entresto Dose administered when BP was below acceptable parameters (SBP<100mmHg) on 11/15/2024, 11/17/2024, 11/24/2024, and 11/30/2024. During a follow up concurrent interview and record review of Resident 1's chart with the DON on 12/20/2024 at 2:52 PM, the DON acknowledged that the DON's name was attached on the second drug-to-drug interactions severe warning dated 10/30/2024 at 2:30 PM indicating that she (DON) had cleared the flagged drug-to-drug interactions. The DON admitted and stated that she had not notified a physician about the above drug-to-drug interactions severe warning per facility protocol Adverse Consequences and Medication Errors. During an interview on 12/21/24 at 11:35 AM, the facility's Medical Director (MD- Also Resident 1's physician) stated Resident 1 had a history of cardiac issues and events. MD stated she was not aware that the facility was holding/not administering Metoprolol Succinate ER 50 mg, Amiodarone HCL 200 mg, Spironolactone 25 mg, or Entresto 24-26 mg to Resident 1. MD stated MD was not aware that Resident 1 received Metoprolol Succinate ER, Amiodarone HCL, Spironolactone, or Entresto outside ordered parameters. MD stated the facility should have notified MD immediately upon discovering medications were being held. During a review of a Policy and Procedure (P&P) titled Administering Medications, revised 1/2024 indicated, Medications shall be administered in a safe and timely manner, and as prescribed. The same P&P included the following policy interpretation and implementation: i. Medications must be administered in accordance with the orders, including any required time frame. ii. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns. iii. The following information must be checked/verified for each resident prior to administering medication: a. Allergies to medications; and b. Vital signs, if necessary. During a review of a P&P titled Adverse Consequences and Medication Error, reviewed 1/2024 indicated, The interdisciplinary team evaluates medication usage in order to prevent and detect adverse consequences and medication related problems such as adverse drug reactions (ADRs) and side effects. Adverse consequences shall be reported to the Attending Physician and Pharmacist, and to federal 055136 Page 6 of 32 055136 12/22/2024 Berkley West Healthcare Center 1623 Arizona Avenue Santa Monica, CA 90404

F 0580 Level of Harm - Minimal harm or potential for actual harm agencies as appropriate. the same P&P defined consequence as an unpleasant symptom or event that is due to or associated with a medication, such as an impairment or decline in an individual's mental or physical condition or functional or psychosocial status. An adverse consequence may include: a. Adverse drug/medication reaction. Residents Affected - Some b. Side effect. c. Medication-medication interaction; During a review of a Policy and Procedure (P&P) titled Change in a Resident's Condition or Status, revised 1/2024 indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). the same P&P indicated the following under policy interpretation and implementation: 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): 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 three (3) or more consecutive times). i. specific instruction to notify the physician of changes in the resident's condition. 055136 Page 7 of 32 055136 12/22/2024 Berkley West Healthcare Center 1623 Arizona Avenue Santa Monica, CA 90404

F 0624 Prepare residents for a safe transfer or discharge from the nursing home. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to provide a safe and orderly discharge for one of the three of the three sampled residents (Resident 1) by failing to reassess Resident 1's Vital Signs (VS - basic functions of your body. which include body temperature, blood pressure [BP], pulse, and respiratory [breathing] rate) who was known to have low BPs prior to discharging the resident on [DATE]. On [DATE] Resident 1 received these medications: metoprolol, spironolactone, Entresto, amiodarone, a Lidoderm 5% patch and a second dose of Lidoderm 5% patch. Residents Affected - Few As a result, on [DATE] at 1:20 PM, the facility discharged Resident 1 to an alternate living facility (ALF) via the facility provided transportation. The ALF pronounced Resident 1 deceased /dead upon arrival. Cross reference: F580, F760, F757, F842 Findings: A review of Resident 1's admission Record, indicated the facility admitted the resident on [DATE], with diagnosis that included acute (sudden) on chronic (long-term) systolic cardiac heart failure (a specific type of heart failure that occurs in the heart's left ventricle), paroxysmal A-Fib (fast and irregular heartbeat), essential hypertension (HTN: high blood pressure that is not due to another medical condition), ST-elevation myocardial infarction (STEMI, type of heart attack that is more serious and has a greater risk of serious complications and death) involving coronary artery of anterior wall (the artery supplies blood to the front portion of your heart), sick sinus syndrome (a disease in which the heart's natural pacemaker located in the upper right heart chamber (right atrium) becomes damaged and is no longer able to generate normal heartbeats at the normal rate), rheumatic disorders of both mitral valves (lies between the left atria and the left ventricle) and tricuspid valves (lies between the right atrium and the right ventricle). A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated [DATE], indicated the resident had moderately impaired cognition (ability to think, read, learn, remember, reason, express thoughts, and make decisions). The MDS indicated the resident was dependent on staff for toileting, lower body dressing, and putting on and taking off footwear. The MDS indicated the resident required substantial/maximal assistance (helper does more than half the effort) with showering/bathing, upper body dressing, and personal hygiene. A review of Resident 1's Order Summary Report dated [DATE], indicated Resident 1 was on the following medications: a. Amiodarone HCI Oral tablet 200 mg give one tablet by mouth one time a day for A-fib. b. Metoprolol Succinate Extended Release (ER) Oral Tablet 24 Hour 50 mg give one tablet by mouth one time a day for HTN hold for SBP <100 and HR<60. c. Spironolactone Oral tablet 25mg give 0.5 tablet by mouth one time a day for CHF hold for SBP <100. d. Entresto Oral tablet 24-26mg give 0.5mg by mouth two times a day for HTN for SBP <100. 055136 Page 8 of 32 055136 12/22/2024 Berkley West Healthcare Center 1623 Arizona Avenue Santa Monica, CA 90404

F 0624 Level of Harm - Minimal harm or potential for actual harm e. Lidoderm Patch 5% (Lidocaine) apply to left thigh topically one time a day for pain management and remove per schedule. The order did not indicate what the schedule was. A review of Resident 1's MAR for [DATE] at 8:13 am, indicated the resident was administered a Lidoderm patch 5% topically on [DATE] at 8:13 am. Residents Affected - Few A review of Resident 1's MAR for [DATE] at 9am, indicated the resident was administered Amiodarone HCL 200 mg oral tablet a day for A-Fib hold for Apical pulse <60 (per pharmacy recommendation), Metoprolol Succinate ER (extended release) 50 mg Oral Tab ER 1 tab one time day for HTN hold for Systolic Blood Pressure (SBP - is the first/top BP number which measures the pressure blood pushing against the artery walls when the heart beats) less than (<)100 mmHg and HR<60 beats per minute, Spironolactone Oral tablet 25mg give 0.5 tab a day for Congestive Heart Failure (CHF- weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs) hold for SBP <100, and Entresto 24-26mg give 0.5mg two times a day for HTN hold for SBP <100 as per indicated parameters. A review of Resident 1's Weights and Vitals Summary dated [DATE] at 8:16 am, indicated the resident's last documented pulse was taken on [DATE] at 8:16 am and was 84 bpm. A review of Resident 1's Weights and Vitals Summary dated [DATE] at 8:16 am, indicated the resident's last documented BP was taken on [DATE] at 8:16 am and was 104/69mmHG (lying l/arm). A review of Resident 1's MAR for [DATE]/9/2024 at 1:23 pm, indicated Resident 1 was administered a second patch on [DATE] at 1:23 pm. The MAR did not indicate the patch applied on [DATE] at 8:13 am was removed. A review of Resident 1's nurses notes dated [DATE] at 1:20 pm, indicated resident discharged home with caregiver in provided transportation via wheelchair. no complaints of pain or discomfort. resident signed all paperwork and leftover medications were given as ordered. resident escorted to transportation by staff. MD and family aware. The vital signs indicated on the note were taken on [DATE] at 8:16 am: BP 104/69, T97.2, P64, RR18, O2 97% RA. The notes did not indicate vital signs were taken prior to discharge. During an interview with Licensed Vocational Nurse (LVN)1 on [DATE] at 10:48 am, LVN1 stated if BP meds were not taken regularly, stopped, held for days, and then started again the resident's BP could fluctuate in a negative way and the body would have to readjust to taking the medication. During a telephone interview on [DATE] at 12:07 pm, the pharmacy consultant (PC) stated it was important to check BP and pulse especially if a resident was on multiple blood pressure medications because by administering multiple antihypertensives the risk was present of the BP and pulse going down. The PC stated if on an antiarrhythmic such as Amiodarone it was very important to monitor the apical pulse because Amiodarone specifically affects the pulse, and the residents ran the risk of the pulse going down and increased the risk for fainting and dizziness. The PC stated vital signs can change depending on the patient's movement, behavior, what they have eaten, and time between other medications, the blood pressure fluctuates even hour to hour you may get some variations 20 minutes you know it's not like a cholesterol where you check every now and then. The PC stated if a resident was on multiple antihypertensives and antiarrhythmics it was important to administer the medications regularly because when you take them on a regular basis your body will stabilize itself where you know if there are peaks and valleys, and the blood pressure will regulate that, so you won't have all of 055136 Page 9 of 32 055136 12/22/2024 Berkley West Healthcare Center 1623 Arizona Avenue Santa Monica, CA 90404

F 0624 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few those up and down fluctuations. The PC was asked what could happen if the that can kind of like alter your system in terms of the blood pressure regulation that can kind of like alter your system in terms of the blood pressure regulation medication were held for two to three days at time and then administered, the PC stated, that can kind of like alter your system in terms of the blood pressure regulation. During a follow up concurrent interview and record review of Resident 1's chart with LVN1 on [DATE] at 1:50 pm, LVN 1 stated that Resident 1 did not like to get up out of bed much. LVN1 stated that she was not aware about any interactions between Resident 1's BP meds but recalled that she (LVN1) had to hold BP meds because of the low BPs. LVN1 admitted to holding Resident 1's following medication doses with no evidence of checking Resident 1's VS on the following days: a) Amiodarone dose was held with no documented apical pulse on 11/29, 11/30, 12/2, 12/3, and 12/8. b) Amiodarone dose was administered with no documented apical pulse on 12/1, 12/4, 12/5, 12/6, 12/7, and 12/9. c) Metoprolol dose was held with no documented BP or pulse on 11/4, 11/7, 11/13, 11/19, 11/20, and 11/26, 12/1, 12/7, and 12/8. d) Metoprolol dose administered when BP was below acceptable parameters on 11/24, 11/28, and 11/29. e) Spironolactone dose was held with no documented BP or pulse on 11/4, 11/7, 11/13, 11/19, 11/20, 11/26, 12/1, 12/7, and 12/8. f) Spironolactone dose administered when BP was below acceptable parameters on 11/17, 11/24, 11/30. g) Entresto dose was held with no documented BP or pulse on 11/4, 11/7, 11/13, 11/19, 11/20, 11/26, 12/1, 12/7, and 12/8. h) Entresto Dose administered when BP was below acceptable parameters on 11/15, 11/24, and 11/30. LVN 1 stated that when someone that is usually in a lying position sits up may affect BP by lowering. On [DATE] at 8:13 am, Resident 1's BP was at 104mmHG and all four medications (metoprolol, amiodarone, Entresto, and spironolactone) were administered to Resident 1. Additionally, a lidocaine patch was applied to Resident 1's left thigh. During Resident 1's discharge about 1 pm, Resident 1 was administered an additional patch to the same site (left thigh) without any evidence of the previous patch being removed by a different LVN. Resident 1 was placed in a wheelchair and placed in the facility provided non-emergency transportation and transported while sitting in the wheelchair. LVN1 admitted that she did not recheck resident 1's VS. During a follow up concurrent interview and record review of Resident 1's chart with the DON on [DATE] at 2:52 pm, the DON stated that BP levels may drop if a person goes from lying to sitting down. The DON stated that VS signs upon discharge must be current but confirmed that Resident 1's VS were not rechecked upon discharge at 1:20 pm. During a review of a Policy and Procedure (P&P) titled TRANSFER OR DISCHARGE DOCUMENTATION dated 1/2024, indicated 055136 Page 10 of 32 055136 12/22/2024 Berkley West Healthcare Center 1623 Arizona Avenue Santa Monica, CA 90404

F 0624 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 4. When a resident is transferred or discharged from the facility, the following information will be documented in the medical record: . f. A summary of the resident's overall medical, physical, and mental condition: . 7.Should a resident be transferred or discharged for any reason, the following information will be communicated to the receiving facility or provider: . g. All other necessary information, including a copy of the resident's discharge summary, and any other documentation, as applicable, to ensure a safe and effective transition of care. 055136 Page 11 of 32 055136 12/22/2024 Berkley West Healthcare Center 1623 Arizona Avenue Santa Monica, CA 90404

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, for one of six sampled residents (Resident 1) the facility failed to Residents Affected - Some 1. Monitor the vital signs (VS) which included blood pressure (BP), apical pulse (AP- a pulse point on the chest that gives the most accurate reading of a heart rate), and heart rate (HR-Pulse), according to physician's order for the following medications: a. Amiodarone HCL (Medication to treat/control very rapid and irregular pulse]) 200 milligrams (mg - unit of measurement) oral tablet a day for atrial fibrillation (A-Fib, serious medical condition of the heart: fast and irregular heartbeat) hold for apical pulse <60, Amiodarone dose was held or given with no documented apical pulse on 11/29, 11/30, 12/1, 12/2, 12/3, 12/4, 12/5, 12/6, 12/7, 12/8, and [DATE]. b. Metoprolol Succinate (Medication to treat/control high blood pressure) Extended Release (ER) 50 mg Oral Tab ER 1 tab one time day for hypertension (HTN- high blood pressure) hold for systolic blood pressure (SBP-top number of BP ready) <100 millimeters of mercury (mmHg, unit of pressure) and HR<60, dose was held with no documented BP or HR on 11/4, 11/7, 11/13, 11/19, 11/20, 11/26, 12/1, 12/7, and [DATE]. Metoprolol dose administered when BP was below acceptable parameters (SBP<100mmHg) on 11/24, 11/28, and [DATE]. c. Spironolactone (Medication to treat/control HTN) oral tablet 25mg give 0.5 tab a day for congestive heart failure (CHF- weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs) hold for SBP <100, dose was held with no documented BP on 11/4, 11/7, 11/13, 11/19, 11/20, 11/26, 12/1, 12/7, and [DATE]. Spironolactone dose administered when BP was below acceptable parameters (SBP<100mmHg) on 11/15, 11/17, 11/24, and [DATE]. d. Entresto (Medication for heart failure) 24-26mg give 0.5mg two times a day for HTN hold for SBP <100 as per indicated parameters. Entresto dose was held with no documented BP on 11/4, 11/7, 11/13, 11/19, 11/20, 11/25, 11/26, 12/1, 12/7, and [DATE]. Entresto Dose administered when BP was below acceptable parameters (SBP<100mmHg) on 11/15, 11/17, 11/24, and [DATE]. 2. Monitor for potential adverse consequences by ensuring the licensed staff will not ignore or override when amiodarone and metoprolol were triggered for severe drug to drug interaction (Adverse drug Reaction [ADR]- harmful or unpleasant reactions to a medication that can be life-threatening) if administered together could result in hypotension, bradycardia (slow heart rate), cardiac arrest, and death. 3. Monitor the responses to or effects of a medications to Resident 1 by analyzing the trend of the vital signs. 4. Resident 1 did not get an excessive dose of Lidoderm patch 5% topically (onto skin) by receiving two doses on [DATE] at 8:13 AM and [DATE] at 1:23 PM. As result, on [DATE] at 9 PM, Resident 1 received all these medications (metoprolol, spironolactone, Entresto, amiodarone, and 2 doses of Lidoderm 5% patch). On [DATE] at 1:20 PM, the facility discharged Resident 1 to the Assisted Living Facility (ALF- a facility for people who need help with daily care, but not as much help as a nursing home provides) via the facility provided non-emergency 055136 Page 12 of 32 055136 12/22/2024 Berkley West Healthcare Center 1623 Arizona Avenue Santa Monica, CA 90404

F 0757 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some transportation. Upon arrival of Resident 1 to the AFL resident was pronounced deceased /dead upon arrival. Cross Reference: F580, F624, F760, F842 On [DATE] at 6:09 PM, while onsite, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ-a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) situation for the facility's failure to: 1. Adequately monitor the parameter per physician order of the following medications: Amiodarone HCL 200 mg oral tablet a day for A-Fib hold for Apical pulse <60 (per pharmacy recommendation), Metoprolol Succinate ER 50 mg Oral Tab ER 1 tab one time day for HTN hold for SBP <100 and HR<60, Spironolactone Oral tablet 25mg give 0.5 tab a day for CHF hold for SBP <100, Entresto 24-26mg give 0.5mg two times a day for HTN hold for SBP <100 as per indicated parameters. 2. Monitor for potential adverse consequences by ensuring the licensed staff will not ignore or override when amiodarone and metoprolol were triggered for severe drug to drug interaction if administered together could result in hypotension, bradycardia, cardiac arrest, and death. 3. Resident 1 did not get an excessive dose of Lidoderm patch 5% topically by receiving two doses on [DATE] at 8:13 AM and [DATE] at 1:23 PM. Administering these medications (metoprolol, spironolactone, Entresto, amiodarone, a Lidoderm 5% patch and second Lidoderm 5% patch) which were known to have severe drug-to-drug interactions without adequate monitoring may result arrhythmias, severe hypotension, bradycardia, and cardiac arrest, including death. On [DATE] at 9 am, Resident 1 received these medications (metoprolol, spironolactone, Entresto, amiodarone, a Lidoderm 5% patch and at 1:17 PM, second Lidoderm 5% patch) and was discharged via the facility provided transportation to an assisted living, Resident 1 was pronounced deceased upon arrival to AFL. On [DATE] at 9:55 PM, while onsite, the SSA removed the IJ after the facility submitted an acceptable removal plan (interventions to correct the deficient practices) which was verified and confirmed through observation, interview, and record review. The acceptable removal plan was as follows: On [DATE], the facility contracted with an outside Pharmacist Consultant to conduct a baseline Medication Regimen Review of residents who resided in the facility on [DATE] for the period beginning [DATE] through [DATE]; to identify other residents potentially affected by missing order parameters, inadequate monitoring, and/or requiring dose adjustments due to medications repeatedly being held. Recommendations were referred to Director of Nursing for follow-up and/or Physician consultation as 055136 Page 13 of 32 055136 12/22/2024 Berkley West Healthcare Center 1623 Arizona Avenue Santa Monica, CA 90404

F 0757 indicated. Level of Harm - Immediate jeopardy to resident health or safety On [DATE], the facility contracted with an outside Physician to conduct a medication regimen review of the facility residents. The outside contracted Physician will collaborate with the outside contracted Pharmacy Consultant regarding the reviews. Residents Affected - Some On [DATE] the outside contracted Pharmacy Consultant reviewed in-house residents' medication regimen from [DATE] through [DATE] with the following summary of audit findings: MRR completed for 42 Residents on [DATE]. 33 Residents noted with orders for parameters and monitoring without any irregularities identified. 6 Residents noted with an irregularity in following Physician's ordered parameters. An outside Consultant Pharmacist educated Director of Nursing Services, and Clinical Nurse Resource Consultant on [DATE] at 10 PM regarding: Safe Medication Administration; Alerting Nurses of Drug-to-Drug interaction prior to Medication Administration; Importance of Adhering to Ordered Medication Parameters; Physician Notification; and Importance of Pharmacist Performing a Thorough Medication Regimen Review (MRR). On [DATE], the facility contracted with an outside Nurse Consultant to conduct in-services and complete the medication administration observations of the licensed nurses. The Director of Nursing Services (DNS) educated licensed nurses on Safe Medication Administration; Alerting Nurses of Drug-to-Drug interaction prior to Medication Administration; Importance of Adhering to Ordered Medication Parameters; Physician Notification; and Importance of Pharmacist Performing a Thorough Medication Regimen Review (MRR) and Medication Administration Technique; and expectations on consulting with physicians as indicated. This training started [DATE] for in-house staff, with remaining staff educated prior to the start of their shift. As of [DATE] at 11am, 12 of 14 nurses (5 Registered Nurses [RN] and 9 License Vocational Nurses [LVNs] total on staff) have completed training (4 RNs + 8 LVNs); for the remaining 2 nurses, 1 LVN will be trained by [DATE]; and 1 RN on LOA will receive training prior to working her shift upon her return. As of [DATE] (4) Registry-LVNs have been in-serviced. Moving forward any Registry Staff will be in-service prior to working their scheduled shift. Licensed Nurses will be educated on Safe Medication Administration; Alerting Nurses of Drug-to-Drug interaction prior to Medication Administration; Importance of Adhering to Ordered Medication Parameters; Physician Notification; and Importance of Pharmacist Performing a Thorough Medication Regimen Review (MRR) and Medication Administration Technique and follow-up expectations upon hire and annually. Training will be completed with the Director of Nursing Services (DNS) and documentation will be retained on training records. DNS educated Licensed Nurses on safe medication administration practices using the 10 Rights of administration; administering meds in accordance with physician ordered monitoring parameters, promptly 055136 Page 14 of 32 055136 12/22/2024 Berkley West Healthcare Center 1623 Arizona Avenue Santa Monica, CA 90404

F 0757 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some notifying Physician of significant drug-to-drug interactions; and importance of facilitating new admission, change-of-condition, and monthly Medication Regimen Reviews (MRRs); and promptly reviewing and remediating MRR findings when indicated. This training will begin 12-20-24 for in-house staff, and remaining staff will be educated prior to the start of their shift. As of [DATE] at 7 PM, total licensed nursing staff 5 Registered Nurses (RNs) and 9 Licensed Vocational Nurses (LVNs) of which 4 RNs and 8 LVNs have completed training; the remaining 2 nurses, 1 LVN will be trained by [DATE]; and 1 RN on LOA will receive training prior to her return. As of [DATE] four (4) Registry-LVNs have been in-serviced. Moving forward any Registry Staff will be in-service prior to working their scheduled shift. Licensed Nurses will receive training upon hire and annually on safe medication administration practices using the 10 Rights of administration; administering meds in accordance with physician ordered monitoring parameters, promptly notifying Physician of significant drug-to-drug interactions; and importance of facilitating new admission, change-of-condition, and monthly Medication Regimen Reviews (MRRs); and promptly reviewing and remediating MRR findings when indicated. Training will be completed with the Director of Nursing Services and documentation will be retained on training records. Medication Pass Competency Assessments will be completed with Licensed Nurses upon hire and annually by Facility Director of Nursing Services (DON), Director of Staff Development (DSD), or Pharmacy Nurse Consultant. Competencies will include verifying proper/safe medication administration practices and compliance with physician ordered administration parameters. New admissions, those experiencing a change-of-condition, and no less often than monthly, a thorough MRR will be conducted through our contracted Pharmacy to identify drug-to-drug interactions and medications requiring dose adjustments (i.e. held frequently). The facility contracted with an outside Pharmacist Consultant [DATE] to conduct a concurrent Medication Regimen Review each month for a minimum of 3 months at which time it will be re-evaluated by the Quality Assessment and Assurance (QAA) Committee for further recommendation. The facility contracted a Medical Records Consultant to conduct concurrent audits with our facility Medical Records Director to monitor Licensed Nurse compliance adhering to ordered medication parameters and contacting Physician's for dose adjustments when indicated (i.e. frequently held). Audits started [DATE] and continue weekly for a minimum of 3 months at which time it will be re-evaluated by the QAA Committee for further recommendation. Beginning [DATE], Director of Nursing Services (DON) is responsible for monitoring Pharmacy compliance of new admission reviews, change of condition, and monthly medication regimen reviews; and coordinating prompt MRR remediation and follow-up. Each month, DON will report MRR compliance thresholds for completion and remediation to the facility's QAA Committee for analysis and remedial planning or monitoring needs as indicated. The Director of Nursing Services (DON) beginning [DATE] will conduct 3 random med pass observations each week x's 3 months, then monthly x's 3 months, then quarterly thereafter to monitor compliance with safe medication administration practices and following ordered parameters where indicated. DON will be responsible for reporting compliance with med pass observations and results to the facility's QA Committee for analysis and remedial planning or monitoring needs as indicated. 055136 Page 15 of 32 055136 12/22/2024 Berkley West Healthcare Center 1623 Arizona Avenue Santa Monica, CA 90404

F 0757 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Facility Medical Records Director (MRD) beginning [DATE] will conduct medication administration record audits of in-house Residents each week x's 3 months, then monthly x's 3 months, then quarterly thereafter to monitor Licensed Nurse compliance adhering to ordered medication parameters and consulting Physicians on dose adjustments when indicated (i.e. frequently held). The audit results will be reported to the Administrator and Director of Nursing for appropriate corrective action. MRD will be responsible for reporting compliance with order parameters and dose adjustment consults to facility's QA Committee for analysis and remedial planning or monitoring needs as indicated it will be re-evaluated for a minimum of 3 months at which time it by the QAA Committee for further recommendation. Findings: A review of Resident 1's admission Record, indicated the facility admitted the resident on [DATE], with diagnosis that included acute (sudden) on chronic (long-term) systolic cardiac heart failure (a specific type of heart failure that occurs in the heart's left ventricle), paroxysmal A-Fib (fast and irregular heartbeat), essential hypertension (HTN: high blood pressure that is not due to another medical condition), ST-elevation myocardial infarction (STEMI, type of heart attack that is more serious and has a greater risk of serious complications and death) involving coronary artery of anterior wall (the artery supplies blood to the front portion of your heart), sick sinus syndrome (a disease in which the heart's natural pacemaker located in the upper right heart chamber (right atrium) becomes damaged and is no longer able to generate normal heartbeats at the normal rate), rheumatic disorders of both mitral valves (lies between the left atria and the left ventricle) and tricuspid valves (lies between the right atrium and the right ventricle). A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated [DATE], indicated the resident had moderately impaired cognition (ability to think, read, learn, remember, reason, express thoughts, and make decisions). The MDS indicated the resident was dependent on staff for toileting, lower body dressing, and putting on and taking off footwear. The MDS indicated the resident required substantial/maximal assistance (helper does more than half the effort) with showering/bathing, upper body dressing, and personal hygiene. A review of Resident 1's Order Summary Report dated [DATE], indicated Resident 1 was on the following medications: a. Amiodarone HCI Oral tablet 200 mg give one tablet by mouth one time a day for A-fib hold for Apical pulse <60 (per pharmacy recommendation). b. Metoprolol Succinate Extended Release (ER) Oral Tablet 24 Hour 50 mg give one tablet by mouth one time a day for HTN hold for SBP <100 and HR<60. c. Spironolactone Oral tablet 25mg give 0.5 tablet by mouth one time a day for CHF hold for SBP <100. d. Entresto Oral tablet 24-26mg give 0.5mg by mouth two times a day for HTN for SBP <100. e. Lidoderm Patch 5% (Lidocaine) apply to left thigh topically one time a day for pain management and remove per schedule. The order did not indicate what the schedule was. A review of Resident 1's Progress Notes for 10/2024, indicated medication administration orders had triggered a severe drug to drug interaction between Metoprolol Succinate ER and Amiodarone HCL on 055136 Page 16 of 32 055136 12/22/2024 Berkley West Healthcare Center 1623 Arizona Avenue Santa Monica, CA 90404

F 0757 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some [DATE] at 8:37 PM, [DATE] at 10:29 AM, [DATE] at 2:38 PM, and [DATE] at 4:08 PM. The progress notes indicated Interaction: Administration of Amiodarone HCI Oral Tablet 200 mg and Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 100 mg may result in severe bradycardia, hypotension and cardiac arrest. The progress notes did not indicate a physician was notified of the severe drug to drug interaction on any of the aforementioned dates. A review of Resident 1's Progress Notes dated [DATE] at 8:45 PM, indicated a medication administration order had triggered a severe drug to drug interaction between Metoprolol Succinate ER and Amiodarone HCL. The progress notes indicated Interaction: Administration of Amiodarone HCI Oral Tablet 200 mg and Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 100 mg may result in severe bradycardia, hypotension and cardiac arrest. The note did not indicate the physician was notified of the severe drug to drug interaction. A review of Resident 1's Medication Administration Record (MAR) for 11/2024, indicated Amiodarone HCL oral tablet a day for A-Fib hold for apical pulse <60 (per pharmacy recommendation) start date [DATE]. The MAR had a section to document the resident's BP but did not have a section to document the resident's pulse. The MAR indicated administration was as follows: 11/292024: Dose held, BP 99/67 mmHg, (per vital sign documentation pulse was 71 bpm [did not indicate if apical] on [DATE] at 9:34 am). The pulse did not indicate if checked apically. [DATE]: Dose held, BP 99/70 mmHg, pulse not indicated. No pulse documented in medical record for [DATE] at 9 am. if checked apically as ordered. A review of Resident 1's MAR for 11/2024, indicated to administer Metoprolol Succinate ER oral, one tab one time day (9 AM) for HTN and to hold the medication for SBP <100 mmHg and HR<60 per minute. The MAR further indicated the following about Metoprolol ER: [DATE]: Dose held. No documented BP or HR/AP BP not indicated/documented in Resident 1's chart (no vital signs documented in medical record) [DATE]: Dose held, BP or pulse not indicated/documented (no vital signs documented in medical record) [DATE]: Dose held, BP or pulse not indicated/documented (no vital signs documented in Resident 1's chart) [DATE]: Dose held, BP or pulse not indicated/documented (no vital signs documented in medical record). [DATE]: Dose held, BP or pulse not indicated/documented on the MAR or on medical records. [DATE]: Dose administered, BP 93/66 mmHg, pulse 66. [DATE]: Dose administered, BP 90/60 mmHg, pulse 74. [DATE]: Dose administered, BP 99/67 mmHg, pulse 71. The 11/2024 MAR did not indicate a physician was notified for held metoprolol ER and for VS 055136 Page 17 of 32 055136 12/22/2024 Berkley West Healthcare Center 1623 Arizona Avenue Santa Monica, CA 90404

F 0757 parameters out of prescribed range. Level of Harm - Immediate jeopardy to resident health or safety A review of Resident 1's MAR for 11/2024, indicated Spironolactone Oral tablet 25mg give 0.5mg one tab a day (9am) for CHF hold for SBP <100 administration was as follows: [DATE]: Dose held; BP not documented on the MAR or on medical records. Residents Affected - Some [DATE]: Dose held; BP not documented on the MAR or on medical records. [DATE]: Dose held; BP not documented on the MAR or on medical records. [DATE]: Dose administered, BP 90/60 mmHg [BP taken at 11:02 am] (parameter indicated hold for SBP <100) [DATE]: Dose administered BP 90/60 mmHg. [DATE]: Dose held, BP and pulse not documented on the MAR or on medical records. [DATE]: Dose held, BP not indicated, pulse not documented (no vital signs documented in medical record) [DATE]: Dose administered, BP 93/66 mmHg [BP taken at 11:16 am] [DATE]: Dose held; BP not indicated on MAR. [DATE]: Dose held, BP not indicated, pulse not documented (no vital signs documented in medical record). [DATE]: Dose administered, BP 99/70 mmHg. The 11/2024 MAR did not indicate a physician was notified for held Spironolactone Oral tablet 25mg give 0.5mg and for VS parameters out of prescribed range. A review of Resident 1's MAR for 11/2024, indicated Entresto 24-26mg give 0.5mg two times a day for HTN hold for SBP <100 administration was as follows: [DATE]: Dose held; BP not documented on the MAR or on medical records. [DATE]: Dose held; BP not documented (no vital signs documented in medical record) [DATE]: Dose held; BP not documented (no vital signs documented in medical record) [DATE]: Dose administered, BP 90/60 mmHg [BP taken at 11:02 AM] (parameter indicated hold for SBP <100) [DATE]: Dose administered BP 90/60 mmHg [DATE]: Dose held, BP and pulse not documented on the MAR or on medical records. 055136 Page 18 of 32 055136 12/22/2024 Berkley West Healthcare Center 1623 Arizona Avenue Santa Monica, CA 90404

F 0757 [DATE]: Dose held, BP and pulse not documented on the MAR or on medical records. Level of Harm - Immediate jeopardy to resident health or safety [DATE]: Dose administered, BP 93/66 mmHg [BP taken at 11:16 am] Residents Affected - Some [DATE]: Dose held, BP not documented on the MAR or on medical records. [DATE]: Dose held; BP not documented on MAR. [DATE]: Dose administered, BP 99/70 mmHg. The 11/2024 MAR did not indicate a physician was notified for held Entresto 24-26 mg give 0.5 mg and for VS parameters out of prescribed range. A review of Resident 1's MAR for 12/2024, indicated Amiodarone HCL 200mg oral tablet a day for A-Fib hold for Apical pulse <60 (per pharmacy recommendation) administration was as follows: [DATE]: Dose administered, BP 97/65 mmHg, Apical pulse not documented. [DATE]: Dose held, BP 98/59 mmHg, Apical pulse not documented. [DATE]: Dose held, BP 101/50 mmHg, Apical pulse not documented. [DATE]: Dose administered, BP 96/62 mmHg, Apical pulse not documented. [DATE]: Dose administered, BP112/76 mmHg, Apical pulse not documented. [DATE]: Dose administered, BP 104/61 mmHg, Apical pulse not documented. [DATE]: Dose administered; Apical pulse not documented. [DATE]: Dose held; Apical pulse not documented. [DATE]: dose administered, BP 104/69 mmHg, Apical pulse not documented. The 12/2024 MAR did not indicate a physician was notified for held Amiodarone HCL Oral tablet 200mg and for VS parameters out of prescribed range. A review of Resident 1's MAR for 12/2024, indicated Metoprolol Succinate ER Oral Tab ER 1 tab one time day for HTN hold for SBP <100 and HR<60 administration was as follows: [DATE]: Dose held, BP and pulse not documented (no vital signs documented in medical record). [DATE]: Dose held, BP and pulse not documented on the MAR or on medical records. [DATE]: Dose administered, BP 104/69 mmHg, pulse 84. A review of Resident 1's MAR for 12/2024, indicated Spironolactone Oral tablet 25mg give 0.5mg one tab a day for CHF hold for SBP <100 administration was as follows: 055136 Page 19 of 32 055136 12/22/2024 Berkley West Healthcare Center 1623 Arizona Avenue Santa Monica, CA 90404

F 0757 [DATE]: Dose held; no BP documented on the MAR. VS not documented on medical records. Level of Harm - Immediate jeopardy to resident health or safety [DATE]: Dose held; no BP documented. VS not documented in medical records. Residents Affected - Some [DATE]: administered, BP 104/69 mmHg. [DATE]: Dose held; no BP documented. VS not documented in medical records. A review of Resident 1's MAR for 12/2024, indicated Entresto 24-26mg give 0.5mg two times a day for HTN hold for SBP <100 administration was as follows: [DATE]: 9 AM: Dose held; BP not documented. [DATE]: 9 AM: Dose held; BP not documented. [DATE]: 9 AM: Dose held; BP not documented in medical records. [DATE]: 9 AM: Administered, BP 104/69 mmHg. A review of Resident 1's MAR for [DATE] at 8:13 AM, indicated Resident 1 was administered a Lidoderm patch 5% topically (onto skin). A review of Resident 1's MAR for [DATE], indicated Resident 1 was administered a second Lidoderm patch on [DATE] at 1:23 PM as recorded in MAR (a discrepancy from the time of discharge of 1:20 PM. Actual application was at 1 pm per LVN1 interview). The MAR did not indicate the Lidoderm patch applied on [DATE] at 8:13 AM was removed. A review of Resident 1's physician's Skilled Nursing Facility Discharge Medication Reconciliation Note dated [DATE] at 9:23 AM, indicated Resident 1 was to be discharged on amiodarone 200 mg 1 tablet by mouth daily, Entresto 24-26 mg 0.5 tablet by mouth twice a day, Lidocaine 5% patch 12 hours on and 12 hours off, metoprolol succinate 50 mg 1 tablet daily, Spironolactone 25mg 0.5mg tablet daily in the morning. A review of Resident 1's Nurses Notes dated [DATE] at 1:20 PM, indicated Resident discharged home with caregiver in provided transportation via wheelchair. No complaints of pain or discomfort. Resident signed all paperwork and leftover medications were given as ordered. Resident escorted to transportation by staff. MD and family aware. The nurses noted indicated Resident 1's VS were taken on [DATE] at 8:16 AM; BP 104/69, T97.2, P64, RR18, O2 97% RA. The nurses' notes did not indicate the resident's vital signs were taken prior to discharge. During an interview on [DATE] at 11:57 AM, Assisted Living Facility Staff (AFL 1) stated on [DATE] at around 1:30 PM Resident 1 arrived at the facility (AFL) there were no sign of life, paramedics were called, and cardiopulmonary resuscitation (CPR) started. Resident 1 was pronounced dead at approximately 2 PM. During an interview on [DATE] at 1:27 PM, the Director of Staff Development (DSD) stated CNAs and CNs are responsible for assessing VS, and that VS needed for medication administration are assessed by the licensed nurses 10 to 15 minutes prior to medication administration because the side effects of the medication can cause low BP, low heartrate (bradycardia), or syncope. DSD stated, it was 055136 Page 20 of 32 055136 12/22/2024 Berkley West Healthcare Center 1623 Arizona Avenue Santa Monica, CA 90404

F 0757 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some important to check BP timely to ensure the BP remained within a normal range because BP medications could work too well and cause hypotension. DSD stated a resident's physician must be informed of three consecutive low BP readings. DSD stated VS must be within ordered parameters must be within range before the medications are administered to mitigate (lessen) adverse (negative) reactions from the medications and had to be followed for resident safety. DSD stated if BP medications are given outside of ordered parameters the residents BP could drop low, which could result in death due to lack of circulation. DSD stated if VS are ordered to such as to assess apical pulse, the documentation must indicate apical pulse was taken. DSD stated the EHR alerts the nurses of any drug-to-drug interactions. DSD defined drug to drug interactions as two drugs (medications) given together that can cause harm and can increase the likelihood of harm. DSD stated the RNS oversee and act on drug to drug to interactions. DSD stated when the EHR alerts facility staff of severe drug to drug interactions, staff must take immediate action and must contact/notify the resident's physician. During an interview on [DATE] at 10:48 AM, LVN1 stated certified nursing assistants (CNAs) are in charge of checking VS and the charge nurses (CNs) were responsible for checking medication administration VS such as BP. LVN1 stated CNAs document the VS in the VS log and the CNs document the VS on the MAR. LVN1 stated VS are taken within 15minutes before medication administration because the VS can change. LVN1 stated medications could be administered an hour before or after the ordered time. LVN1 restated it was important to take a BP timely with medication administration because the BP could change. LVN1 defined parameters as the recommended scale that must be followed to give certain medications at the proper dose such as BP and blood sugar (BS) medications. LVN1 stated if parameters are not followed the results could be detrimental (harmful) and dangerous to a resident's health. LVN1 stated if ordered, apical pulse must be assessed apically and documented as apical pulse on the MAR. LVN1 stated registered nurse supervisors (RNS) are responsible for inputting medication orders and acting upon severe drug to drug interaction warnings. LVN1 stated the physician must be notified immediately of all severe drug to drug interaction warnings. LVN1 stated physician must be notified of all changes in condition in resident status and VS taken at the time of the change of condition otherwise the residents could receive the wrong treatment. During an interview on [DATE] at 11:54 am, the Director of Nursing (DON) stated care plan must include resident's condition, diagnosis/es, . black box warnings to ensure residents are provided with appropriate care during their stay at the facility. The DON stated if specific interventions and orders for cardiac medication administration are not carried out as per physician's orders can result in the resident experiencing hypotension or hypertension. The DON stated when administering medications the CNs are responsible for assessing VS. The DON stated VS must be documented on the vital signs logs and must be taken prior to medication administration because if the BP is too low and medications are given can result in hypotension, shock (a life-threatening emergency in which the organs cannot function properly), and syncope (fainting or passing out). The DON stated parameters are placed on medication orders to ensure resident safety and that it was important to administer medications as ordered to improve the resident's condition/outcome. The DON stated BP/cardiac medications must not be administered without current VS because the VS could change. The DON stated if a physician ordered a specific VS such as apical pulse the nurses must check the apical pulse for one full minute (pointed to her [DON] left rib area of the chest location) to check the apical pulse. The DON stated she was not sure if the electronic health record (EHR) was set up to allow the nurses to document an apical pulse was taken but stated that documentation must be specific and must indicate an apical pulse was assessed. The DON stated drug to drug interactions are first reviewed by the facility's contracted pharmacy and then the pharmacy notifies the 055136 Page 21 of 32 055136 12/22/2024 Berkley West Healthcare Center 1623 Arizona Avenue Santa Monica, CA 90404

F 0757 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some facility. The DON stated after the pharmacy notifies the facility, the facility contacts the resident the resident's physician to check if it is okay for the resident to receive medications (Spironolactone, Amiodarone, Entresto, and Metoprolol) together. The DON stated the facility must notify a resident's physicians of drug to drug-to-drug interactions immediately, regardless of if the drug-to-drug interactions indicates mild or severe. During a telephone interview on [DATE] at 12:07 PM, the pharmacy consultant (PC) stated it was important to review BP and pulse especially if a resident is on multiple blood pressure medications because of the risk for hypotension and bradycardia. The PC stated it was very important to monitor the apical pulse when a resident is on an antiarrhythmic such as amiodarone because amiodarone specifically affects the pulse, and the residents is at risk for bradycardia, fainting, and dizziness. The PC stated it was important the check the apical pulse for one full minute when a resident is on amiodarone because that is where the most accurate pulse is be obtained. The PC stated it was important the check the vital signs at the time of medication administration because the vital signs can change depending on the patient's movement, behavior, what they have eaten, and time between other medications, the blood pressure fluctuates even hour to hour you may get some variations 20 minutes. The PC stated the nurses administering the medications are responsible to adhere to the parameters set by the physician and if the medications are being held multiple days the nurses should have notified the physician of the continued need to hold the medications. The PC stated the nurses administering the medications are responsible for notifying the physician if the vital signs are continuously out of the parameters. During a follow up interview and record review of drug-to-drug interaction [TRUNCATED] 055136 Page 22 of 32 055136 12/22/2024 Berkley West Healthcare Center 1623 Arizona Avenue Santa Monica, CA 90404

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure, one out of 3 sampled residents (Resident 1) were free of significant medication errors (an error in medication administration that may jeopardizes a resident's health and/or safety) by not administering the following medications withhold parameters (conditions for administration indicated in the physician order based on vital sign measurements) Residents Affected - Some a. Metoprolol Succinate (Medication to treat/control high blood pressure) Extended Release (ER) 50 milligrams (mg - unit of measurement) Oral Tab ER 1 tab one time day for hypertension (HTN- high blood pressure) hold for systolic blood pressure (SBP-top number of BP ready) <100 millimeters of mercury (mmHg, unit of pressure) and HR<60, Metoprolol dose administered when BP was below acceptable parameters (SBP<100mmHg) on 11/24/2024, 11/28/2024, and 11/29/2024. b. Spironolactone (Medication to treat/control HTN) oral tablet 25mg give 0.5 tab a day for congestive heart failure (CHF- weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs) hold for SBP <100, Spironolactone dose administered when BP was below acceptable parameters (SBP<100mmHg) on 11/15/24, 11/17/2024, 11/24/2024, and 11/30/2024. c. Entresto (Medication for heart failure) 24-26mg give 0.5mg two times a day for HTN hold for SBP <100 as per indicated parameters. Entresto Dose administered when BP was below acceptable parameters (SBP<100mmHg) on 11/15/2024, 11/17/24, 11/24/2024, and 11/30/2024. This significant medication error was a deficient practice that increased the risk that Resident 1could have experienced adverse effects (potentially harmful side effects) related to medication administration errors which could have resulted in medical complications possibly leading to hospitalization or death. Cross Reference: F580, F624, F757, F842 Findings: A review of Resident 1's admission Record, indicated the facility admitted the resident on 10/24/24, with diagnosis that included acute (sudden) on chronic (long-term) systolic cardiac heart failure (a specific type of heart failure that occurs in the heart's left ventricle), paroxysmal A-Fib (fast and irregular heartbeat), essential hypertension (HTN: high blood pressure that is not due to another medical condition), ST-elevation myocardial infarction (STEMI, type of heart attack that is more serious and has a greater risk of serious complications and death) involving coronary artery of anterior wall (the artery supplies blood to the front portion of your heart), sick sinus syndrome (a disease in which the heart's natural pacemaker located in the upper right heart chamber (right atrium) becomes damaged and is no longer able to generate normal heartbeats at the normal rate), rheumatic disorders of both mitral valves (lies between the left atria and the left ventricle) and tricuspid valves (lies between the right atrium and the right ventricle). A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 10/24/24, indicated the resident had moderately impaired cognition (ability to think, read, learn, remember, reason, express thoughts, and make decisions). The MDS indicated the resident was dependent on staff for toileting, lower body dressing, and putting on and taking off footwear. The MDS indicated the resident required substantial/maximal assistance (helper does more than half the effort) with 055136 Page 23 of 32 055136 12/22/2024 Berkley West Healthcare Center 1623 Arizona Avenue Santa Monica, CA 90404

F 0760 showering/bathing, upper body dressing, and personal hygiene. Level of Harm - Minimal harm or potential for actual harm A review of Resident 1's Order Summary Report dated 10/24/2024, indicated Resident 1 was on the following medications: Residents Affected - Some a. Metoprolol Succinate Extended Release (ER) Oral Tablet 24 Hour 50 mg give one tablet by mouth one time a day for HTN hold for SBP <100 and HR<60. b. Spironolactone Oral tablet 25mg give 0.5 tablet by mouth one time a day for CHF hold for SBP <100. c. Entresto Oral tablet 24-26mg give 0.5mg by mouth two times a day for HTN for SBP <100. A review of Resident 1's Medication Administration Record (MAR) for 11/2024, indicated to administer Metoprolol Succinate ER oral, one tab one time day (9 AM) for HTN and to hold the medication for SBP <100 mmHg and HR<60 per minute. The MAR further indicated the following about Metoprolol ER: 11/24/2024: Dose administered, BP 93/66 mmHg, pulse 66. 11/28/2024: Dose administered, BP 90/60 mmHg, pulse 74. 11/29/2024: Dose administered, BP 99/67 mmHg, pulse 71. A review of Resident 1's MAR for 11/2024, indicated Spironolactone Oral tablet 25 mg give 0.5 mg one tab a day (9 AM) for CHF hold for SBP <100 administration was as follows: 11/15/2024: Dose administered, BP 90/60 mmHg [BP taken at 11:02 am] (parameter indicated hold for SBP <100) 11/17/2024: Dose administered BP 90/60 mmHg. 11/24/2024: Dose administered, BP 93/66 mmHg [BP taken at 11:16 am] 11/30/2024: Dose administered, BP 99/70 mmHg. A review of Resident 1's MAR for 11/2024, indicated Entresto 24-26mg give 0.5mg two times a day for HTN hold for SBP <100 administration was as follows: 11/15/2024: Dose administered, BP 90/60 mmHg [BP taken at 11:02 AM] (parameter indicated hold for SBP <100) 11/17/224: Dose administered BP 90/60 mmHg 11/24/2024: Dose administered, BP 93/66 mmHg [BP taken at 11:16 am] 11/30/2024: Dose administered, BP 99/70 mmHg. During an interview on 12/17/24 at 1:27 PM, the Director of Staff Development (DSD) stated DSD 055136 Page 24 of 32 055136 12/22/2024 Berkley West Healthcare Center 1623 Arizona Avenue Santa Monica, CA 90404

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated, it was important to check BP timely to ensure the BP remained within a normal range because BP medications could work too well and cause hypotension. DSD stated VS must be within ordered parameters must be within range before the medications are administered to mitigate (lessen) adverse (negative) reactions from the medications and had to be followed for resident safety. DSD stated if BP medications are given outside of ordered parameters the residents BP could drop low, which could result in death due to lack of circulation. During an interview on 12/19/24 at 10:48 AM, License Vocational Nurses (LVN1) stated certified nursing assistants (CNAs) are in charge of checking VS and the charge nurses (CNs) were responsible for checking medication administration VS such as BP. LVN1 restated it was important to take a BP timely with medication administration because the BP could change. LVN1 defined parameters as the recommended scale that must be followed to give certain medications at the proper dose such as BP and blood sugar (BS) medications. LVN1 stated if parameters are not followed the results could be detrimental (harmful) and dangerous to a resident's health. During an interview on 12/19/24 at 11:54 am, the Director of Nursing (DON) stated when administering medications the CNs are responsible for assessing VS. The DON stated VS must be documented on the vital signs logs and must be taken prior to medication administration because if the BP is too low and medications are given can result in hypotension, shock (a life-threatening emergency in which the organs cannot function properly), and syncope (fainting or passing out). The DON stated parameters are placed on medication orders to ensure resident safety and that it was important to administer medications as ordered to improve the resident's condition/outcome. During an interview on 12/20/24 at 11:32 am, LVN2 stated BP must be checked prior to administering BP medications to ensure medications are administered only when the VS are within the ordered parameters and that a resident is in a condition to take their medications as ordered by a physician, otherwise the BP could get too low which may result in death. LVN2 stated that medications should not be given or held without checking VS. On 11/28/2024, Resident 1's SBP was 90/60. LVN2 admitted to administering the following medications: Metoprolol 50 mg (Hold if SBP less [<] than 100mmHG) Entresto oral tabs 24-26mg (hold SBP < 100) Spironolactone oral tab (hold SBP < 100) On 11/29/2024, Resident 1's SBP was 99/67. LVN2 admitted to administering the following medications: Metoprolol 50 mg (Hold if SBP less [<] than 100mmHG) Entresto oral tabs 24-26mg (hold SBP < 100) Spironolactone oral tab (hold SBP < 100) LVN2 confirmed that the above medications should have been held because they were under the ordered parameters. A review of a Policy and Procedures (P&P) titled Administering Medications, revised 1/2024 055136 Page 25 of 32 055136 12/22/2024 Berkley West Healthcare Center 1623 Arizona Avenue Santa Monica, CA 90404

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some indicated, Medications shall be administered in a safe and timely manner, and as prescribed. The same P&P included the following policy interpretation and implementation: i. Medications must be administered in accordance with the orders, including any required time frame. ii. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns. iii. The following information must be checked/verified for each resident prior to administering medication: . b. Vital signs, if necessary. 055136 Page 26 of 32 055136 12/22/2024 Berkley West Healthcare Center 1623 Arizona Avenue Santa Monica, CA 90404

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and record review, the facility failed to maintain complete and accurate medical record in accordance with accepted professional standards and practices for one out of 3 sampled residents (Resident 1) for the following medications: a. Amiodarone HCL (Medication to treat/control very rapid and irregular pulse]) 200 milligrams (mg - unit of measurement) oral tablet a day for atrial fibrillation (A-Fib, serious medical condition of the heart: fast and irregular heartbeat) hold for apical pulse <60, Amiodarone dose was held or given with no documented apical pulse on 11/29, 11/30, 12/1, 12/2, 12/3, 12/4, 12/5, 12/6, 12/7, 12/8, and 12/9/2024. b. Metoprolol Succinate (Medication to treat/control high blood pressure) Extended Release (ER) 50 mg Oral Tab ER 1 tab one time day for hypertension (HTN- high blood pressure) hold for systolic blood pressure (SBP-top number of BP ready) <100 millimeters of mercury (mmHg, unit of pressure) and HR<60, dose was held with no documented BP or HR on 11/4, 11/7, 11/13, 11/19, 11/20, 12/1, 12/7, and 12/8/2024. c. Spironolactone (Medication to treat/control HTN) oral tablet 25mg give 0.5 tab a day for congestive heart failure (CHF- weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs) hold for SBP <100, dose was held with no documented BP on 11/4, 11/7, 11/13, 11/19, 11/20, 11/26, 12/1, 12/7, and 12/8/2024. d. Entresto (Medication for heart failure) 24-26mg give 0.5mg two times a day for HTN hold for SBP <100 as per indicated parameters. Entresto dose was held with no documented BP on 11/4, 11/7, 11/13, 11/19, 11/20, 11/25, 11/26, 12/1, 12/7, and 12/8/2024. These deficient practices had the potential to result in confusion in provision of care and services for Resident 1 and places Resident 1 at risk of not receiving appropriate treatment due to incomplete medical care information. Cross Reference: F580, F624, F757, F760 Findings: A review of Resident 1's admission Record, indicated the facility admitted the resident on 10/24/24, with diagnosis that included acute (sudden) on chronic (long-term) systolic cardiac heart failure (a specific type of heart failure that occurs in the heart's left ventricle), paroxysmal A-Fib (fast and irregular heartbeat), essential hypertension (HTN: high blood pressure that is not due to another medical condition), ST-elevation myocardial infarction (STEMI, type of heart attack that is more serious and has a greater risk of serious complications and death) involving coronary artery of anterior wall (the artery supplies blood to the front portion of your heart), sick sinus syndrome (a disease in which the heart's natural pacemaker located in the upper right heart chamber (right atrium) becomes damaged and is no longer able to generate normal heartbeats at the normal rate), rheumatic disorders of both mitral valves (lies between the left atria and the left ventricle) and tricuspid valves (lies between the right atrium and the right ventricle). A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 10/24/24, 055136 Page 27 of 32 055136 12/22/2024 Berkley West Healthcare Center 1623 Arizona Avenue Santa Monica, CA 90404

F 0842 Level of Harm - Minimal harm or potential for actual harm indicated the resident had moderately impaired cognition (ability to think, read, learn, remember, reason, express thoughts, and make decisions). The MDS indicated the resident was dependent on staff for toileting, lower body dressing, and putting on and taking off footwear. The MDS indicated the resident required substantial/maximal assistance (helper does more than half the effort) with showering/bathing, upper body dressing, and personal hygiene. Residents Affected - Some A review of Resident 1's Order Summary Report dated 10/24/2024, indicated Resident 1 was on the following medications: a. Amiodarone HCI Oral tablet 200 mg give one tablet by mouth one time a day for A-fib hold for apical pulse <60. b. Metoprolol Succinate Extended Release (ER) Oral Tablet 24 Hour 50 mg give one tablet by mouth one time a day for HTN hold for SBP <100 and HR<60. c. Spironolactone Oral tablet 25mg give 0.5 tablet by mouth one time a day for CHF hold for SBP <100. d. Entresto Oral tablet 24-26mg give 0.5mg by mouth two times a day for HTN for SBP <100. A review of Resident 1's Medication Administration Record (MAR) for 11/2024, indicated Amiodarone HCL oral tablet a day for A-Fib hold for apical pulse <60 (per pharmacy recommendation) start date 11/29/24. The MAR had a section to document the resident's BP but did not have a section to document the resident's apical pulse. The MAR indicated administration was as follows: 11/292024: Dose held, BP 99/67 mmHg, (per vital sign documentation pulse was 71 bpm [did not indicate if apical] on 11/29/24 at 9:34 am). The pulse did not indicate if checked apically. 11/30/2024: Dose held, BP 99/70 mmHg, pulse not indicated. No pulse documented in medical record for 11/30/24 at 9 am. if checked apically as ordered. A review of Resident 1's MAR for 11/2024, indicated to administer Metoprolol Succinate ER oral, one tab one time day (9 AM) for HTN and to hold the medication for SBP <100 mmHg and HR<60 per minute. The MAR further indicated the following about Metoprolol ER: 11/4/2024: Dose held. No documented BP or HR/AP BP not indicated/documented in Resident 1's chart (no vital signs documented in medical record) 11/7/2024: Dose held, BP or pulse not indicated/documented (no vital signs documented in medical record) 11/13/2024: Dose held, BP or pulse not indicated/documented (no vital signs documented in Resident 1's chart) 11/19/2024: Dose held, BP or pulse not indicated/documented (no vital signs documented in medical record). 11/20/2024: Dose held, BP or pulse not indicated/documented on the MAR or on medical records. 055136 Page 28 of 32 055136 12/22/2024 Berkley West Healthcare Center 1623 Arizona Avenue Santa Monica, CA 90404

F 0842 A review of Resident 1's MAR for 11/2024, indicated Spironolactone Oral tablet 25mg give 0.5mg one tab a day (9am) for CHF hold for SBP <100 administration was as follows: Level of Harm - Minimal harm or potential for actual harm 11/4/2024: Dose held; BP not documented on the MAR or on medical records. Residents Affected - Some 11/7/2024: Dose held; BP not documented on the MAR or on medical records. 11/13/2024: Dose held; BP not documented on the MAR or on medical records. 11/19/2024: Dose held, BP not documented on the MAR or on medical records. 11/20/2024: Dose held; BP not documented (no vital signs documented in medical record) 11/26/2024: Dose held; BP not documented (no vital signs documented in medical record). 11/30/2024: Dose administered, BP 99/70 mmHg. A review of Resident 1's MAR for 11/2024, indicated Entresto 24-26mg give 0.5mg two times a day for HTN hold for SBP <100 administration was as follows: 11/4/2024: Dose held; BP not documented on the MAR or on medical records. 11/7/2024: Dose held; BP not documented (no vital signs documented in medical record) 11/13/2024: Dose held; BP not documented (no vital signs documented in medical record) 11/20/2024: Dose held, BP not documented on the MAR or on medical records. 11/25/2024: Dose held; BP not documented on MAR. 11/26/2024: Dose held, BP not documented on the MAR or on medical records. A review of Resident 1's MAR for 12/2024, indicated Amiodarone HCL 200mg oral tablet a day for A-Fib hold for Apical pulse <60 (per pharmacy recommendation) administration was as follows: 12/1/2024: Dose administered; Apical pulse not documented. 12/2/2024: Dose held; Apical pulse not documented. 12/3/2024: Dose held; Apical pulse not documented. 12/4/2024: Dose administered; Apical pulse not documented. 12/5/2024: Dose administered; Apical pulse not documented. 12/6/024: Dose administered; Apical pulse not documented. 12/7/2024: Dose administered; Apical pulse not documented. 055136 Page 29 of 32 055136 12/22/2024 Berkley West Healthcare Center 1623 Arizona Avenue Santa Monica, CA 90404

F 0842 12/8/2024: Dose held; Apical pulse not documented. Level of Harm - Minimal harm or potential for actual harm 12/9/2024: dose administered; Apical pulse not documented. Residents Affected - Some A review of Resident 1's MAR for 12/2024, indicated Metoprolol Succinate ER Oral Tab ER 1 tab one time day for HTN hold for SBP <100 and HR<60 administration was as follows: 12/1/2024: Dose held, BP and pulse not documented (no vital signs documented in medical record). 12/7/2024: Dose held, BP and pulse not documented on the MAR or on medical records. 12/8/2024: Dose held; no BP documented. A review of Resident 1's MAR for 12/2024, indicated Spironolactone Oral tablet 25mg give 0.5mg one tab a day for CHF hold for SBP <100 administration was as follows: 12/1/24: Dose held; no BP documented on the MAR. VS not documented on medical records. 12/7/2024: Dose held; no BP documented. VS not documented in medical records. 12/8/2024: Dose held; no BP documented. VS not documented in medical records. A review of Resident 1's MAR for 12/2024, indicated Entresto 24-26mg give 0.5mg two times a day for HTN hold for SBP <100 administration was as follows: 12/1/2024: 9 AM: Dose held; BP not documented. 12/7/2024: 9 AM: Dose held; BP not documented. 12/8/2024: 9 AM: Dose held; BP not documented in medical records. During an interview on 12/17/24 at 1:27 PM, the Director of Staff Development (DSD) stated CNAs and CNs are responsible for assessing vital signs (VS), and that VS needed for medication administration are assessed by the licensed nurses 10 to 15 minutes prior to medication administration because the side effects of the medication can cause low BP, low heartrate (bradycardia), or syncope. DSD stated, it was important to check BP timely to ensure the BP remained within a normal range because BP medications could work too well and cause hypotension. DSD stated if VS are ordered to such as to assess apical pulse, the documentation must indicate apical pulse was taken. During an interview on 12/19/24 at 10:48 AM, LVN1 stated certified nursing assistants (CNAs) are in charge of checking VS and the charge nurses (CNs) were responsible for checking medication administration VS such as BP. LVN1 stated CNAs document the VS in the VS log and the CNs document the VS on the MAR. During an interview on 12/19/24 at 11:54 am, the Director of Nursing (DON) stated when administering medications the CNs are responsible for assessing VS. The DON stated VS must be documented on the vital signs logs and must be taken prior to medication administration because if the BP is too low and medications are given can result in hypotension, shock (a life-threatening emergency in which the organs cannot function properly), and syncope (fainting or passing out). 055136 Page 30 of 32 055136 12/22/2024 Berkley West Healthcare Center 1623 Arizona Avenue Santa Monica, CA 90404

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a telephone interview on 12/19/2024 at 12:07 PM, the pharmacy consultant (PC) stated it was important to review BP and pulse especially if a resident is on multiple blood pressure medications because of the risk for hypotension and bradycardia. The PC stated it was very important to monitor the apical pulse when a resident is on an antiarrhythmic such as amiodarone because amiodarone specifically affects the pulse, and the residents is at risk for bradycardia, fainting, and dizziness. The PC stated it was important the check the apical pulse for one full minute when a resident is on amiodarone because that is where the most accurate pulse is be obtained. The PC stated it was important the check the vital signs at the time of medication administration because the vital signs can change depending on the patient's movement, behavior, what they have eaten, and time between other medications, the blood pressure fluctuates even hour to hour you may get some variations 20 minutes. During an interview on 12/20/24 at 11:32 am, LVN2 stated BP must be checked prior to administering BP medications to ensure medications are administered only when the VS are within the ordered parameters and that a resident is in a condition to take their medications as ordered by a physician, otherwise the BP could get too low which may result in death. LVN2 stated that medications should not be given or held without checking VS. LVN2 stated that an apical pulse is checked at the apex (the pointed end of the heart) on the left side of the chest and is checked with a stethoscope for one full minute. The documentation must indicate a pulse was checked apically. A review of a Policy and Procedures (P&P) titled Administering Medications, revised 1/2024 indicated, Medications shall be administered in a safe and timely manner, and as prescribed. The same P&P included the following policy interpretation and implementation: i. Medications must be administered in accordance with the orders, including any required time frame. ii. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns. iii. The following information must be checked/verified for each resident prior to administering medication: a. Allergies to medications; and b. Vital signs, if necessary. A review of the facility's P&P, titled, Charting and Documentation, revised date 1/22024, indicated All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record . 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 7. Documentation of procedures and treatments will include care-specific details, including: a. the date and time the procedure/treatment was provided; 055136 Page 31 of 32 055136 12/22/2024 Berkley West Healthcare Center 1623 Arizona Avenue Santa Monica, CA 90404

F 0842 b. the name and title of the individual(s) who provided the care; Level of Harm - Minimal harm or potential for actual harm c. the assessment data and/or any unusual findings obtained during the procedure/treatment; d. how the resident tolerated the procedure/treatment; Residents Affected - Some e. whether the resident refused the procedure/treatment; f. notification of family, physician or other staff, if indicated; 055136 Page 32 of 32