Inspection visit
Health inspection
7 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 7 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0583
Keep residents' personal and medical records private and confidential.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to ensure staff implemented its policy
and procedures on Health Insurance Portability and Accountability Act (HIPAA- is a U.S. federal law that
protects sensitive patient/resident/client health information (PHI) from unauthorized disclosure, ensuring
privacy, security, and data integrity while also allowing for health insurance portability and administrative
efficiency in healthcare) for one of one resident (Resident 52). This deficient practice violated the privacy
and confidentiality rights of Resident 52. Findings: During record review, Resident 52's admission Record
indicated the facility admitted Resident 52 on 12/7/2025 with diagnoses including Type 2 Diabetes Mellitus
(DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension
(HTN-high blood pressure). During record review, Resident 52's Minimum Data Set (MDS-A resident
assessment tool) dated 12/29/2025, indicated Resident 52 had intact cognitive skills (mental ability to make
decisions of daily living). During an observation and concurrent record review on 01/05/2026 at 12:09 PM
Resident 52 was observed in bed receiving a bag of Sodium Chloride Solution 0.9% (NS 0.9%- Is a
saltwater solution used medically for fluid/electrolyte replacement, wound/eye irrigation, nebulization to
loosen mucus, and in laboratories for cell washing) intravenous (IV-into a vein) infusion at 100 milliliters
(ml-unit of measurement) per hour (hr) via dial flow (a manual IV administration set with a built-in dial to
control the flow rate [mL/hour] of fluids or medications). A telephone physician's order was taped/attached
on the NS 0.9% solution bag and had the following information:. Resident 52's name, date of birth (DOB)
and room number Date of 1/4/2026 at 3:36 PM Facility name, address, fax number, and phone number.
Order ID Number. Order Summary: Sodium Chloride Solution 0.9% intravenous use at 100 mL/hour.
Confirmed by Registered Nurse Supervisor (RNS) 1. During an observation, interview, and concurrent
record review in the presence of the director of nursing (DON) on 01/05/2026 at 2:45 PM, RNS 1 stated
that HIPAA protects residents from sharing information to others who should not have their personal
information; RNS 1 observed and read the physician's order attached/taped on Resident 52's IV NS 0.9%
solution bag. RNS 1 stated the physician's order included Resident 52's name and DOB. RNS 1 stated the
NS 0.9% solution IV bag was taken directly from the facility's emergency kit (e-kit). RNS 1 stated that IV
bags do not come with a labels and so she printed the physician's order and taped it on Resident 52's IV
bag. During an interview on 01/07/2026 at 2:11 PM, RNS 1 stated HIPAA protects patient privacy and that
private information is not seen by other residents, staff, family members, and/or visitors and that all staff/all
health care workers must comply with HIPAA law. RNS 1 stated that residents can become upset and
betrayed when their protected information is displayed for anyone to see and retrieve without their
permission. During record review, the facility's policy and procedures (P&P) titled HIPAA Compliance'
revised on 4/2025, indicated, POLICY. It is the intent of the facility to adhere to the Omnibus Health
Insurance Portability and Accountability Act (HIPAA) Privacy, Security, Enforcement and Breach Notification
Rules. Transaction Code Sets, Enforcement guidance and related requirements
Residents Affected - Few
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 8
Event ID:
055136
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055136
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/08/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Berkley West Healthcare Center
1623 Arizona Avenue
Santa Monica, CA 90404
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0583
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
of the Health Insurance Portability and Accountability Act (HIPAA). It is our intent to assure that policies,
procedures and practices are developed, implemented, staff trained breaches avoided and compliance
monitored.2. The facility will adopt guidelines and procedures that are compliant with the HIPAA Privacy
and Security Rules and other related HIPAA rules and the practices established by the Rule as well as
other applicable federal and state laws.3. Policies and Procedures and training will include as a minimum: a.
Access to PHI - manual and electronic; b. Accounting of Disclosures including faxes; c. Amendments; d.
Breach and impact rules; e. Business Associates; f. Compliance, monitoring and reporting; g. Designated
Record Set; h. Disclosure with and without Authorizations; i. Marketing and Financing; j. Minimum
Necessary; k. Privacy Practices and Privacy Notice; 1. Sanctions; m. Security requirements. During record
review, the facility's P&P titled Protected Health Information (PHI), Authorization for Use or Disclosure of
Policy Statement All uses and disclosures of revised 3/2014, indicated that, Protected health information
(PHI) beyond those otherwise permitted by current HIPAA law require a signed authorization.1. Policy
Interpretation and Implementation The facility and its business associates have a limited right to use and/or
disclose PHI health information for purposes of treatment, payment, or for the operations of the
organization.2. For other uses, there must be written authorization to release protected health information
unless the law permits or requires the facility to use or disclose this information without authorization.5.
Uses and disclosures of PHI that require written authorization, except as permitted by law, include: a. Use
or disclosure of psychotherapy notes; b. Use or disclosure of PHI for marketing purposes; or c. The sale of
PH?. Uses or disclosures of PHI that require an opportunity for the individual to agree or object include:a.
Use or disclosure of certain information to maintain a facility directory; (1) The facility will inform individuals
of the type of information that will be used in the directory and the persons to whom the information will be
disclosed.(2) Individuals will be given the opportunity to restrict some or all of the information used or
disclosed in a facility directory.
Event ID:
Facility ID:
055136
If continuation sheet
Page 2 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055136
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/08/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Berkley West Healthcare Center
1623 Arizona Avenue
Santa Monica, CA 90404
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview and record review, the facility failed to provide daily wound treatment per
physician's orders for one of one sampled residents (Resident 42) according to Physician's Orders dated
12/24/2025. This deficient practice had the potential to place Resident 42 at risk for worsening of the
pressure injury.Findings: A review of the Resident 42's admission Record indicated the facility re-admitted
the resident on 12/20/2025, with diagnoses that included stage 3 pressure ulcer (is tissue damage that
results in full-thickness loss of skin and the layer of fat under the skin may be visible), encephalopathy
(brain damage that causes severe confusion and forgetfulness) and dementia (a progressive state of
decline in mental abilities). A review of Resident 42's Minimum Data Set (MDS - a resident assessment
tool), dated 12/24/2025 indicated the resident had one stage 3 pressure wound (ulcer) upon admission. The
MDS also indicated Resident 42 was dependent upon staff to shower, lower body dressing and toileting
hygiene. A review of Resident 42's care plan on impaired skin integrity, initiated 12/21/2025, indicated the
resident had a stage 3 pressure wound (ulcer). The goal was for Resident 42's wound to decrease in size to
not develop skin breakdown. The care plan interventions (specific care and services facility staff need to
provide a resident to promote healing and prevent a worsening of a condition) included to cleanse the site
with normal saline, apply Santyl ointment (medicine that removes dead tissue from wounds so they can
start to heal) and cover with a foam dressing (wound care material) daily. A review of Resident 42's altered
care plan on skin integrity, initiated 12/23/2025, indicated the resident had a pressure injury on the right
lateral lower leg. The care plan indicated the goal was for the resident's skin to be from from signs and
symptoms of redness, swelling and foul smelling drainage. The care plan indicated interventions included to
check resident's skin condition for presence of skin breakdown and to provide the treatment as ordered. A
review of Resident 42's Physician's Orders dated 12/24/2025, indicated the physician ordered the following
treatment orders:- To treat the sacral pressure injury, staff were to apply Santyl (ointment used to remove
damaged tissue from chronic skin ulcers and severely burned areas) to sacrum topically every day shift for
stage 3 pressure injury. - To treat the right later lower leg wound, staff were to cleanse the area with normal
saline (NS - is a mixture of salt and water), pat dry, apply Santyl then cover with an abdominal pad and
wrap with kerlix ( a bulky, crinkled gauze bandage used to cushion, absorb fluid, and protect wounds) daily.
During a concurrent interview and record review on 1/7/2026 at 1:34 PM with Treatment Nurse (TN) 1,
Resident 42's Treatment Administration Records(TAR - a log used by healthcare professionals of all
treatments given to a resident) for the month of December 2025 and January 2026 were reviewed. TN 1
stated Resident 42 was admitted with a stage 3 sacral pressure ulcer and a Stage 3 right lateral leg
pressure ulcer. TN 1 stated Resident 42's wounds are treated daily. TN 1 stated there was no documented
evidence that Resident 42's wounds were treated on 12/27/25, 12/30/2025 and on 1/2/2026. TN 1 stated
treatments are documented to prove that they were completed and wounds are treated in order to improve
the wound. During an interview on 1/8/2026 at 11:45 AM the Director of Nursing (DON) stated, If treatments
are not documented they (treatment) are not done. Importance of wound treatment is to make sure the
wound is treated properly so it doesn't get worse or become infection. The goal is to heal the wound. A
review of the facility's P&P titled, Charting and Documentation, revised 4/2025, indicated the following
information is to be documented in the resident medical record:a. Objective observations;b. Medications
administered;c. Treatments or services performed;d. Changes in the resident's condition;e, Events,
incidents or accidents involving the resident; andf. Progress toward or changes in the care plan goals and
objectives
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055136
If continuation sheet
Page 3 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055136
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/08/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Berkley West Healthcare Center
1623 Arizona Avenue
Santa Monica, CA 90404
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM
and/or mobility, unless a decline is for a medical reason.
Based on observation, interview and record review, the facility failed to ensure one of five sampled
residents (Resident 40), who had limited range of motion (ROM - the extent of movement of a joint) in the
right hand, had a right hand splint applied per the physician's order. This deficient practice placed Resident
5 at increased risk for further decline and contracture formation to the right hand. A review of Resident 40's
admission Record indicated the facility admitted the resident on 10/26/2024 and readmitted the resident on
2/6/2025 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right
dominant side, gait and mobility abnormalities and Diabetes Mellitus (DM-a disorder characterized by
difficulty in blood sugar control and poor wound healing). A review of Resident 40's Quarterly Minimum
Data Set (MDS - a resident assessment tool) dated 10/29/2025 indicated the resident had severely
impaired cognitive skills for daily decision-making. The MDS indicated the resident moderate assistance
with dressing, toileting hygiene and bathing. The MDS also indicated Resident 40 received had limited
range of motion (ROM - extent of movement of a joint) on an upper extremity. A review of Resident 40's
high risk for further contractures on right hand care plan, initiated 10/24/2025, indicated the resident
needed a right hand splint. The care plan interventions included for RNA for right hand/wrist splint
application up to 4 hours as tolerated every day five times a week and to check for further contracture of the
hands and fingers during care. A review of Resident 40's Physician Orders, dated 12/11/2025 indicated the
resident was to receive Restorative Nursing Aide (RNA, assistant that help residents to maintain their
function and joint mobility) for right hand /wrist splint application up to four hours every day five times a
week. During an observation on 1/6/2026 at 9:52 AM, at Resident 40's bedside, Resident 40 was observed
sleeping in bed. Resident 40 was not wearing a right hand splint. During an observation on 1/6/2026 at
12:18 PM, inside the dining Room. Resident 40 was observed eating lunch with his left hand. Resident 40
was not wearing a right hand splint. During an interview and observation on 1/6/2026 at 12:38 PM,
Resident 40 stated the last time he wore the splint was in early December 2025. Resident 40 stated he
would like to wear the splint. Resident 40 also stated he did not know why the splint isn't being applied.
During a concurrent interview and record review on 1/6/2026 at 1:36 PM Restorative Nurse Aide (RNA) 1
stated Resident 40's right hand contracture and Resident 40 had an order to apply a splint to Resident 40's
right hand for four hours a day. RNA 1 stated Resident 40's splint has been missing for around 20 days.
RNA 1 further stated they did not know if a new splint had been ordered. During a concurrent review of the
RNA log book for January 2026, RNA 1 stated there was no log for Resident 40. RNA 1 further stated it
was important for Resident 40 to wear the splint to prevent his right hand contracture from worsening. A
review of the facility's policy and procedures (P&P) titled, Resident Mobility and Range of Motion, revised
4/2025, indicated Residents will not experience an avoidable reduction in range of motion (ROM) and
residents with limited mobility will receive appropriate services, equipment and assistance to maintain or
improve mobility unless reduction in mobility is unavoidable.
Event ID:
Facility ID:
055136
If continuation sheet
Page 4 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055136
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/08/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Berkley West Healthcare Center
1623 Arizona Avenue
Santa Monica, CA 90404
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
Based on interview and record review, the facility failed to provide urinary catheter (a hollow tube inserted
into the bladder to drain or collect urine) care every shift per the resident's physician order for one of four
sampled resident's (Resident 12). This deficient practice had the potential to result in the development of a
urinary tract infection (UTI- an infection in any part of the urinary system, the kidneys, bladder or urethra).A
review of Resident 12's admission record indicated the facility admitted Resident 12 on 11/28/2025 with
diagnoses that included lumbar vertebral fracture (a broken bone in the lower back), urinary retention
(inability to completely empty one's bladder) and diabetes mellitus (DM - a disorder characterized by
difficulty in blood sugar control and poor wound healing). A review of Resident 12's Minimum Data Set
(MDS - a resident assessment tool), dated 12/5/2025, indicated the resident's cognition (ability to acquire
and understand knowledge) was intact. The MDS also indicated the resident had an indwelling urinary
catheter and was not part of a toileting program. The MDS further indicated the resident was dependent
upon staff for toileting hygiene, bathing and dressing. A review of the physician orders, dated 6/10/2025,
indicated Resident 12 was to receive the following care:Foley Catheter size 16 French (Fr - measurement of
the catheter's outer diameter) with 10 milliliter (m-unit of measurement) bulb. Monitor for placement and
function as neededCatheter care for indwelling catheter every shift. Cleanse area every shift monitor for
redness, irritation, swelling, signs and symptoms of urinary tract infection (UTI). A review of Resident 12's
care plan on Has Indwelling Catheter, initiated 12/8/2025, indicated Resident 12 had a urinary catheter due
to urinary retention. The care plan indicated a goal was for the resident to not exhibit signs or symptoms of
urinary infection. The interventions included to monitor for signs/symptoms of UTI which included pain,
burning, blood tinged urine. During an interview on 1/07/2026 at 1:55 PM, Treatment Nurse (TN) 1 stated
Resident 12 had a urinary catheter due to decreased urine output. TN 1 stated urinary catheter care is
provided by nursing staff every shift. TN 1 further stated there was no documentation that catheter care was
provided to Resident 1 on 1/2/2026 during the day shift or on 1/3/2026 during the night shift. TN 1 stated a
potential of outcome of not providing catheter care was that Resident 12 could develop an infection. During
an interview on 1/8/2026 at 11:42, the Director of Nursing (DON) stated if a treatment is not documented it
was not done. The DON further stated it was important to provide catheter care every shift in order to
prevent the resident from developing an infection. A review of the facility's policy and procedures (P&P)
titled, Catheter Care, Urinary, revised 4/2025, indicated, The purpose of this procedure is to prevent
catheter-associated urinary tract infections. A review of the facility's P&P titled, Charting and
Documentation, revised 4/2025, indicated: 2. The following information is to be documented in the resident
medical record:a. Objective observations;b. Medications administered;c. Treatments or services performed;
Event ID:
Facility ID:
055136
If continuation sheet
Page 5 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055136
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/08/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Berkley West Healthcare Center
1623 Arizona Avenue
Santa Monica, CA 90404
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview and record review the facility failed to ensure insulin (a hormone that
regulates blood sugar) for single-patient use (meant for multiple uses for one individual patient/resident) for
Resident 34 was ordered and delivered to the facility timely for one of six residents (Resident 34).As a
result, on 1/6/2026 at 11:15AM, licensed vocational nurse (LVN) 2, dispensed 2 units (unit of measure)
insulin pen (portable medical device used for injecting doses of insulin) that was already in use/circulation
and prescribed specifically for Resident 46 and administered/injected Resident 34 with the same insulin
therefore decreasing/reducing the intended time and doses of the insulin prescribed for Resident 46. Cross
Reference F880 Findings: During a concurrent observation and interview of medication administration on
1/6/2026 at 11:15AM, LVN 2 injected Resident 34 with 2 units of insulin per sliding scale (chart with
prescribed pre-established doses) via insulin pen for a blood sugar test result of 204. An observation/review
of a label on the insulin pen, the label indicated that the insulin was prescribed for Resident 46. During an
interview LVN 2 apologetically stated she accidentally used Resident 46's insulin pen to administer insulin
to Resident 34. LVN 2 further stated Resident 34's insulin pen was in the medication cart, however upon
inspection, there was no insulin found of the medication cart and the medication refrigerator for Resident
34. During a concurrent interview and record review on 1/6/2026 at 11:46 AM, the Director of Staff
Development (DSD) stated a renewal order for Resident 34's insulin pen was completed yesterday
(1/5/2026) during the night shift, the DSD stated facility contracted pharmacy had not delivered Resident
34's ordered insulin medication to the facility. During an interview on 1/8/2026 at 2:45PM, the Director of
Nursing (DON) stated sharing a single-patient insulin pen on any resident other than on the resident that
the insulin was prescribed for, can lead to reduced intended time use of the prescribed dose for the
intended Resident placing residents at risk for serious skin and blood borne diseases that can result in poor
outcomes including death. A review of the facility's policy and procedures (P&P) titled Medication
Administration-General Guidelines dated 04/2025 indicated, Prior to administration, the medication . the
Resident's medication administration record (MAR) is compared with the medication label. Medications
supplied for one resident are never administered to another resident. A review of the facility Licensed
Vocational Nurse Job Description dated 2003, subtitle Drug Administration Functions indicated, Ensure that
prescribed medication for one resident is not administered to another.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055136
If continuation sheet
Page 6 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055136
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/08/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Berkley West Healthcare Center
1623 Arizona Avenue
Santa Monica, CA 90404
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0867
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop
corrective plans of action.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure Resident 8's medical records did not contain
abbreviations not approved by the facility in accordance with the facility's policy and procedures (P&P policy explains the rules and presents them in a logical framework while procedures outline the
step-by-step implementation of various tasks) titled Charting and Documentation with a revision date of
7/2017. This deficient practice had the potential to result in miscommunication between medical and
nursing staff causing delay in providing medical care and services to Resident 8. Findings During a review
of Resident 8's admission record (face sheet - a document containing demographic and diagnostic
information) indicated Resident 8 was admitted to the facility on [DATE] with the following diagnoses:
hemiplegia (paralysis that affects one side of the body) and hemiparesis (weakness or the inability to move
on one side of the body, making it hard to perform everyday activities like eating or dressing), dysphagia
(difficulty swallowing), and acute on chronic diastolic heart failure ( a sudden worsening of long-term
stiffness in the heart's main pumping chamber (left ventricle), making it hard to relax and fill with blood,
leading to fluid backup, shortness of breath, fatigue, and swelling, requiring urgent treatment). During a
review of Resident 8's Hospice (is medical care for people who are expected to live six months or less)
Comprehensive Assessment (identify the physical, psychosocial, emotional, and spiritual needs related to
the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort,
and dignity throughout the dying process) with benefit period dates of 10/17/2025 through 1/14/2026
indicated, Resident 8 was under hospice care. During a review of Resident 8's Minimum Data Set (MDS - a
resident assessment tool) dated 10/23/2025, indicated, Resident 8 had moderately impaired cognition
(make poor decisions, cues and supervisions required) and was dependent on all activities of daily living
(ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for
themselves). During a review of Resident 8's care plan (CP - a guideline for nurses to help them create and
achieve a solid plan of action in the treatment of a patient) with a focus on declining health status, initiated
on 10/18/2025, indicated the CP goal is to keep Resident 8 comfortable and pain will be controlled. The CP
intervention included to observe/report increase pain rate and re-evaluate medication as needed through
hospice. However, the same CP indicated that a staff used the abbreviation PIC but failed to indicate/spell
out what PIC stood for/means. During a review of Resident 8's Hospice Visit Note Report dated 12/30/2025
indicated, Resident 8 had a recent decline in functional status in feeding, bathing, toileting, ambulation,
transfers, feeding, and was now bedbound (someone confined to bed for most or all of their day due to
illness, injury, or physical limitations, requiring assistance). During a review of the facility's In-Service
Education (a professional development for workers aimed to enhance their skills, knowledge, and
competence to improve job performance) dated 1/09/2026 indicated, Several staff were educated on
avoiding abbreviations in patient documentation. During a review of the facility's Abbreviations and Symbols
with a revision date of 9/2013, the document did not include the abbreviation PIC as part of the facility
approved abbreviations. During a review of the facility's policy and procedures (P&P - policy explains the
rules and presents them in a logical framework while procedures outline the step-by-step implementation of
various tasks) titled Charting and Documentation with a revision date of 7/2017 indicated, To ensure
consistency in charting and documentation of the resident's clinical record, only facility approved
abbreviations and symbols may be used when recording entries in the resident's clinical records.
Event ID:
Facility ID:
055136
If continuation sheet
Page 7 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055136
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/08/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Berkley West Healthcare Center
1623 Arizona Avenue
Santa Monica, CA 90404
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview and record review the facility failed to ensure insulin (a hormone that
regulates blood sugar) for single-patient use (meant for multiple uses for one individual patient/resident) for
Resident 34 was ordered and delivered to the facility timely for one of six residents (Resident 34). This
deficient practice placed both Resident 34 and 46 at high risk for infection and transmission of bloodborne
pathogens, including hepatitis B (HBV-a viral infection of the liver), hepatitis C (HCV-a viral infection causing
liver inflammation), and human immunodeficiency virus (HIV- a virus that attacks the body's immune
system).Cross Reference F760 Findings: During a concurrent observation and interview of medication
administration on 1/6/2026 at 11:15AM, LVN 2 injected Resident 34 with 2 units of insulin per sliding scale
(chart with prescribed pre-established doses) via insulin pen for a blood sugar test result of 204. An
observation/review of a label on the insulin pen, the label indicated that the insulin was prescribed for
Resident 46. During an interview LVN 2 apologetically stated she accidentally used Resident 46's insulin
pen to administer insulin to Resident 34. LVN 2 further stated Resident 34's insulin pen was in the
medication cart, however upon inspection, there was no insulin found of the medication cart and the
medication refrigerator for Resident 34. During a concurrent interview and record review on 1/6/2026 at
11:46 AM, the Director of Staff Development (DSD) stated a renewal order for Resident 34's insulin pen
was completed yesterday (1/5/2026) during the night shift, the DSD stated facility contracted pharmacy had
not delivered Resident 34's ordered insulin medication to the facility. During an interview on 1/8/2026 at
2:45PM, the Director of Nursing (DON) stated sharing a single-patient insulin pen on any resident other
than on the resident that the insulin was prescribed for, can lead to reduced intended time use of the
prescribed dose for the intended Resident placing residents at risk for serious skin and blood borne
diseases that can result in poor outcomes including death. A review of the facility's policy and procedures
(P&P) titled Infection Prevention & Control Program dated 04/2025 indicated, An infection and control
program (IPCP) is established . to help prevent the development and transmission of communicable
diseases and infections. Prevention of infection includes educating staff and ensuring that they adhere to
proper techniques and procedures. A review of the facility's P&P titled Medication Administration-General
Guidelines dated 04/2025 indicated, Prior to administration, the medication . the Resident's medication
administration record (MAR) is compared with the medication label. Medications supplied for one resident
are never administered to another resident. A review of the facility Licensed Vocational Nurse Job
Description dated 2003, subtitle Drug Administration Functions indicated, Ensure that prescribed
medication for one resident is not administered to another.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055136
If continuation sheet
Page 8 of 8
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Back to topCitations
7 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F583 - Privacy and Confidentiality
Keep residents' personal and medical records private and confidential.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
F867 - Program feedback, data systems and monitoring
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
FAQ · About this visit
Common questions about this visit
What happened during the January 8, 2026 survey of BERKLEY WEST HEALTHCARE CENTER?
This was a inspection survey of BERKLEY WEST HEALTHCARE CENTER on January 8, 2026. The surveyor cited 7 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at BERKLEY WEST HEALTHCARE CENTER on January 8, 2026?
Yes, 7 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide and implement an infection prevention and control program."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.