Health inspection·March 3, 2025

F 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure safe and orderly discharge from the facility to home for four of five sampled residents (Resident 1, 2, 4 and 5) by failing to: Residents Affected - Some 1. Properly discharge Resident 1 to home by setting up the home health agency with complete instructions for ongoing care according to physician's order. 2. Complete a discharge plan summary upon Resident 1, 2, 4, 5's discharge to home. 3. Complete an Interdisciplinary Team (IDT - a group of dedicated healthcare professionals who work to bring knowledge together to help residents receive the care they need) meeting with services provided by the Social Services department regarding Resident 1, 2, 4 and 5's discharge planning according to facility's policy and procedure (P&P). These deficient practices resulted in incomplete and ineffective discharge planning that led to lack of necessary care after discharge. Findings: A. During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including amyotrophic lateral sclerosis (ALS - commonly known as Lou Gehrigsdisease, is a progressive neurodegenerative disease that affects the motor neurons in the brain and spinal cord), dysphagia (difficulty swallowing) and disorder of muscle (a group of conditions that affect the muscles and their function). The admission Record also indicated; Resident 1 was discharge on [DATE]. During a review of the Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 12/19/2024, the MDS indicated Resident 1's cognitive (relating to mental action or process of acquiring knowledge and understanding) skills for daily decisions was mildly impaired. The MDS indicated Resident 1 required maximal assistance to total dependence from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's Order Summary Report (OSR), dated 1/2/2025, the OSR indicated, Discharge with Home Health Agency (HHA1) with Physical Therapy, Occupational Therapy, Speech Therapy including Durable Medical Equipment (DME -refers to medical devices like wheelchairs, walkers, oxygen equipment, and hospital beds that are designed to be used repeatedly at home): hospital bed and gastrostomy tube (g-tube - is a thin, flexible tube inserted through the abdominal wall directly into the Page 1 of 4 055136 055136 03/03/2025 Berkley West Healthcare Center 1623 Arizona Avenue Santa Monica, CA 90404

F 0660 stomach) supplies. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 1's IDT team meeting [notes], dated 12/17/2024, the IDT meeting [notes] did not include any services provided by Social Services Director (SSD) and any documentation regarding discharge planning of Resident 1. Residents Affected - Some During a review of Resident 1's Progress Notes as of 3/3/2025, the Progress Notes indicated there were no documentations by SSD regarding Resident 1's discharge planning that included HHA1 setup, medications and DME prior to Resident 1's discharge on [DATE]. Additionally, there were no documented notes by SSD regarding follow-up calls regarding Resident 1's status after discharge. During an interview with Family Member 1 (FM 1) on 2/28/2025 at 2:26 p.m., FM 1 stated, Resident 1 was discharged on 1/2/2025 and during discharge instruction, they were informed that HHA1 will be following Resident 1 for ongoing care such as g-tube feeding and physical therapy. FM 1 stated, they waited for HHA1 to call them and set-up after Resident 1 was discharged and did not receive a call. FM 1 stated, she had to call Resident 1's physician to verify the orders and she also called HHA1 to get a clarification in which they confirmed that HHA1 did not get a referral and/or physician's orders from the facility regarding home health services. During an interview with Home Health Administrative Specialist (HHAS) on 2/28/2025 at 2:53 p.m., the HHAS stated, they received the referral for Resident 1's home health services from Resident 1's physician on 2/2/2025. B. During a review of Resident 2's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including fracture of lower end of right femur (a break, crack or crush injury of the thigh bone), depression (a mood disorder that causes persistent feeling of sadness and loss of interest) and disorder of muscle. The admission Record indicated Resident 2 was discharged on 1/10/2025. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decisions were intact. The MDS indicated Resident 2 required maximal assistance to total dependence from staff for ADLs. During a review of Resident 2's OSR, dated 1/10/2025, the OSR indicated, Discharge home with Home Health Agency (HHA2) with Physical Therapy, Occupational Therapy, Registered Nurse with left over medications. During a review of Resident 2's IDT team meeting [notes], dated 12/31/2024, the IDT meeting [notes] did not include any services provided by SSD and any documentation regarding discharge planning of Resident 2. During a review of Resident 2's Progress Notes as of 3/3/2025, the Progress Notes indicated there were no documentations by SSD regarding Resident 2's discharge planning that included HHA2 setup, and medications prior to Resident 2's discharge on [DATE]. Additionally, there were no documented notes by SSD regarding follow-up calls regarding Resident 2's status after discharge. C. During a review of Resident 4's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including multiple fractures of ribs, right side, chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make 055136 Page 2 of 4 055136 03/03/2025 Berkley West Healthcare Center 1623 Arizona Avenue Santa Monica, CA 90404

F 0660 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some it difficult to breathe) and diastolic congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). The admission Record indicated Resident 4 was discharged on 3/1/2025. During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4's cognitive skills for daily decisions were intact. The MDS indicated Resident 4 required maximal assistance from staff for ADLs. During a review of Resident 4's OSR, dated 3/1/2025, the OSR indicated, Discharge home with Home Health Agency (HHA3) with Physical Therapy, Occupational Therapy, Registered Nurse with left over medications. During a review of Resident 4's medical record as of 3/3/2025, the medical record indicated, there were no IDT team meetings conducted, and no documentations on what discharge planning had been completed for Resident 4. During a review of Resident 4's Progress Notes as of 3/3/2025, the Progress notes indicated there were no documentations by SSD regarding Resident 4's discharge planning that included HHA3 setup, and medications prior to Resident 3's discharge 3/1/2025. Additionally, there are no notes by SSD regarding follow-up calls regarding Resident 4's status after discharge. D. During a review of Resident 5's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), end stage renal disease (ESRD-a medical condition in which a person's kidney [organ in the body that lifters waste and excess fluid from the blood] function stop functioning on a permanent basis) and disorder of muscle. The admission Record indicated Resident 5 was discharged on 1/3/2025. During a review of Resident 5's MDS dated [DATE], the MDS indicated Resident 5's cognitive skills for daily decisions were intact. The MDS indicated Resident 2 required maximal assistance to total dependent from staff for ADLs. During a review of Resident 5's OSR, dated 1/3/2025, the OSR indicated, Discharge home with Physical Therapy, Occupational Therapy, Registered Nurse with left over medications. During a review of Resident 5's medical record as of 3/3/2025, the medical record indicated, there were no IDT team meetings conducted, and no documentations on what discharge planning had been completed for Resident 5. During a review of Resident 5's Progress Notes as of 1/3/2025, the Progress Notes indicated there were no documentations by SSD regarding Resident 5's discharge planning that included HHA setup, and medications prior to Resident 5's discharge on [DATE]. Additionally, there were no documented notes by SSD regarding follow-up calls regarding Resident 5's status after discharge. During a concurrent interview and record reviews with Registered Nurse (RN 1) on 3/3/2025 at 12:05 p.m., RN 1 stated, for IDT meeting regarding discharges, they would notify SSD as it is her (SSD) responsibility to setup home health. RN 1 reviewed Resident 1, 2, 4, and 5's medical record and confirmed, there were no documentations completed regarding residents' discharge planning. RN 1 stated residents who were discharged with HHA should be followed up immediately after discharge for continuity 055136 Page 3 of 4 055136 03/03/2025 Berkley West Healthcare Center 1623 Arizona Avenue Santa Monica, CA 90404

F 0660 of care and for safety. Level of Harm - Minimal harm or potential for actual harm During an interview with Director of Nursing (DON) on 3/3/2025 at 12:21 p.m., the DON stated, it is important to ensure the continuity of care for the services to be setup prior to discharging residents in the facility for the safety of the residents. The DON stated, it is also important to make follow-up phone calls with residents to ensure that they are safe after being discharged from the facility. Residents Affected - Some During a review of facility's policy and procedure (P&P), titled, Discharge Summary and Plan, revised on 10/2024, the P&P indicated that, When a resident's discharge is anticipated, a discharge summary and post-discharge plan is developed to assist the resident with discharge . Every resident will be evaluated for his or her discharge needs and will have an individualized postdischarge plan. The post-discharge plan will be developed by the Care Planning/Interdisciplinary Team with the assistance of the resident and his or her family . A copy of the following will be provided to the resident and receiving facility and a copy will be filed in the resident's medical records: a. An evaluation of the resident's discharge needs; b. The post-discharge plan; and c. The discharge summary. 055136 Page 4 of 4