Health inspection·February 16, 2025

F 0641 Ensure each resident receives an accurate assessment. 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: Residents Affected - Few 1. Ensure an accurate Minimum Data Set ([MDS] - a resident assessment tool) was completed accurately for one of 12 sampled residents (Resident 18) by failing to: 1. Ensure Resident 18's Depakote (an anticonvulsant used to treat seizure disorder and other psychiatric conditions) medication was encoded as anticonvulsant and reflected in the MDS assessment under Section N (N0415 High-Risk Drug Classes) medication. This deficient practice resulted in incorrect data transmitted to Center for Medicare and Medicaid Services (CMS) related to inappropriate MDS care screening and assessment tool practices. Findings: During a review of Resident 18's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 18 was admitted to the facility on [DATE]. The admission Record indicated, Resident 18's diagnoses included dementia (a progressive state of decline in mental abilities), Diabetes Mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension ([HTN] - high blood pressure). During a review of Resident 18's MDS assessment, dated 1/22/2025, the MDS indicated, Resident 18's cognitive (ability to think and reason) skills for daily decision making was severely impaired. The MDS indicated, Resident 18 was totally dependent (helper does all of the effort) from staff with toileting hygiene and lower body dressing. During a review of Resident 18's Order Listing Report (a document containing active orders), dated 2/16/2025, the Order Listing Report indicated, Resident 18 has an active order of Depakote 500 milligrams ([mg] - metric unit of measurement, used for medication dosage/and or amount) by mouth at bedtime (9 p.m.) for mood disorder (a mental health condition that involves a persistent change in person's emotional state) manifested by hostile behavior. During a concurrent interview and record review on 2/15/2025 at 2:21 p.m., with the Minimum Data Set Nurse (MDSN), Resident 18's MDS assessment, dated 1/22/2025 was reviewed. The MDSN stated the MDS assessment was completed inaccurately. The MDSN stated Resident 18 was taking Depakote which is considered as anticonvulsant medication and was not checked on the MDS assessment Section N0415. The MDSN stated per Resident Assessment Instrument ([RAI] - a guide that helps nursing home staff use to Page 1 of 6 055196 055196 02/16/2025 Marycrest Manor 10664 St. James Drive Culver City, CA 90230

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assess residents and develop care plans) manual coding of medications should be based on the pharmacological (relating to the use of drugs to treat a condition) classification of the medication not based on the reason it was prescribed. The MDSN stated it was a human error and an oversight on her part by not encoding the Depakote as anticonvulsant medication in the MDS assessment. The MDSN stated accuracy of assessment in the MDS was important because it reflects the care provided by facility staff to the residents. During a review of the facility's policy and procedure (P&P) titled, MDS Assessment, dated 10/15/2021, the P&P indicated, The RAI shall be completed for residents residing in the facility per current RAI manual instructions. 055196 Page 2 of 6 055196 02/16/2025 Marycrest Manor 10664 St. James Drive Culver City, CA 90230

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: Residents Affected - Few 1. Ensure one out of 12 sampled residents (Resident 28) had four padded side rails on the bed per physician's order. This deficient practice had the potential to result in Resident 28 being injured in the event of a seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) Findings: During a review of Resident 28's admission Record, the admission Record indicated Resident 28 was admitted to the facility on [DATE] with diagnoses including hypertension (HTN-high blood pressure), seizures, and dementia (a progressive state of decline in mental abilities). During a review of Resident 28's History and Physical (H&P), dated 6/22/2024, the H&P indicated Resident 28 can make needs known but cannot make medical decisions. During a review of Resident 28's Minimum Data Set ([MDS] a resident assessment tool) dated 12/5/2024, the MDS indicated Resident 28 was dependent on staff for toileting and showering. During a review of Resident 28's care plan, dated 6/20/2024, the care plan indicated Resident 28 required the use of four padded side rails for seizure precautions. The care plan indicated Resident 28 would have padded side rails when in bed. During a concurrent interview and record review on 2/15/2025 at 5:48 p.m. with Licensed Vocational Nurse (LVN) 4, Resident 28's order summary was reviewed. The order summary indicated Resident 28 had a physician's order for four padded side rails to be up when in bed for seizure precautions. During a concurrent observation and interview on 2/15/2025 at 5:50 p.m. with LVN 4 at the bedside of Resident 28, Resident 28 was noted in bed with four unpadded side rails up. LVN 4 stated padded side rails are ordered to decrease the impact and protect from injury during a seizure. 055196 Page 3 of 6 055196 02/16/2025 Marycrest Manor 10664 St. James Drive Culver City, CA 90230

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Ensure one out of 12 sampled residents (Resident 28) was not prescribed Seroquel (an anti-psychotic medication used to treat mental illness) to control dementia (condition where there is a decline in mental abilities and memory) symptoms. This deficient practice put Resident 28 at risk of an adverse reaction (bad outcome) from taking an anti-psychotic without a diagnosis of a mental illness. Findings: During a review of Resident 28's admission Record, the admission Record indicated Resident 28 was admitted to the facility on [DATE] with diagnoses including hypertension (HTN-high blood pressure), seizures, and dementia (a progressive state of decline in mental abilities). During a review of Resident 28's History and Physical (H&P), dated 6/22/2024, the H&P indicated Resident 28 can make needs known but cannot make medical decisions. During a review of Resident 28's Minimum Data Set ([MDS] a resident assessment tool) dated 12/5/2024, the MDS indicated Resident 28 was dependent on staff for toileting and showering. During a concurrent interview and record review with the Director of Staff Development (DSD) on 2/16/2025 at 12:48 p.m., Resident 28's order summary was reviewed. The order summary indicated Resident 28 had a physician's order for Seroquel 25 mg for dementia psychosis. The DSD stated anti-psychotics are given for a psychiatric diagnosis to help manage behavior. The DSD stated Resident 28 does not have a psychiatric diagnosis. The DSD stated Seroquel is not used for dementia. You must be careful giving anti-psychotics to the elderly because they can become very drowsy and it increases their risk for fall. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication, dated July 2022, the P&P indicated the facility will ensure each resident's drug regimen will be free of unnecessary drugs. Doctors orders will contain the appropriate diagnosis. 055196 Page 4 of 6 055196 02/16/2025 Marycrest Manor 10664 St. James Drive Culver City, CA 90230

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. 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: Residents Affected - Few 1. Ensure laboratory test (a medical procedure that analyzes a sample of blood, urine, or other bodily fluid or tissue) was completed as ordered by the physician for one of 12 sampled residents (Resident 18). This deficient practice had the potential for Resident 18 not receiving necessary medical treatment. Findings: During a review of Resident 18's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 18 was admitted to the facility on [DATE]. The admission Record indicated, Resident 18's diagnoses included dementia (a progressive state of decline in mental abilities), Diabetes Mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension ([HTN] - high blood pressure). During a review of Resident 18's MDS assessment, dated 1/22/2025, the MDS indicated, Resident 18's cognitive (ability to think and reason) skills for daily decision making was severely impaired. The MDS indicated, Resident 18 was totally dependent (helper does all of the effort) from staff with toileting hygiene and lower body dressing. During a review of Resident 18's Order Listing Report (a document containing active orders), dated 2/16/2025, the Order Listing Report indicated, Resident 18 has an active order to check the Complete Blood Count ([CBC] - a blood test used to look at overall health conditions and blood disorders), Comprehensive Metabolic panel ([CMP] a test that measures different substances in the blood, and provides important information of your body's chemical balance and how it uses food and energy), Thyroid Stimulating Hormone ([TSH] - a blood test that measures this hormone), Lipid Panel (a blood test that measures the amount of fat in your blood), and hemoglobin A1C (a test that indicates the average level of blood sugar control over the last couple of months, a high number is a sign of poor blood sugar control) on 12/9/2024. During a concurrent interview and record review on 2/15/2024 at 2:31 p.m., with the Director of Nursing (DON), Resident 18's clinical records were reviewed. The DON stated Resident 18's laboratory tests as ordered by the physician on 12/9/2024 was not completed and results were not available. The DON stated Resident 18's physician ordered the laboratory test remotely and did not communicate to the licensed nursing staff. The DON stated it was important for Resident 18's to have a routine blood test to monitor his different diagnoses and clinical condition and to revaluate if the ongoing treatment would continue. During a review of the facility's policy and procedure (P&P) titled, Laboratory and X-ray Services, dated 4/29/2022, the P&P indicated, It is the facility's policy to provide laboratory and x-ray services, as ordered by the physician. 055196 Page 5 of 6 055196 02/16/2025 Marycrest Manor 10664 St. James Drive Culver City, CA 90230

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on interview and record review, the facility failed to: 1. Maintain and notify the dietary supervisor of the temperature being out of range in one of the walk-in refrigerators during the month of February. This deficient practice had the potential for food spoilage and can cause foodborne pathogens in the residents. Findings: During a review of the Refrigerator Temperature Log, dated February 2025, it indicated the walk-in refrigerator located towards the back of the kitchen for February 2025 had the following temperatures recorded: 44 Fahrenheit ( F- measurement of temperature) on 2/6 at 5:00 a.m. 42 F on 2/8 at 5:30 a.m. 45 F on 2/10 at 5:30 a.m. 45 F on 2/11 at 5:40 a.m. During a concurrent interview and record review on 2/16/2025 at 9:30 a.m. with Kitchen Aide (KA), the Refrigerator Temperature Log for February 2025 was reviewed. KA stated that the individual who arrives the earliest, usually around 5:30 a.m. would check the temperatures of the refrigerator and freezer and record it on the temperature log. KA stated they check it when they first come in because the refrigerator and freezer isn't being opened or closed which could affect the temperatures, so the first temperature taken when then first staff member arrives is the most accurate temperature. KA stated there are several dates in February where the refrigerator exceeded 41 F and there were no comments written the in the column for corrective action/comments and there should have been so the staff could see what was done to correct the issue. KA stated that the individual who took the temperature that is out of range need to report it to the dietary supervisor and they are the ones who would fill out the column corrective action/comments. KA further stated it is important for food to be stored at the appropriate temperature because if not the food can go bad and can make the food unsafe to eat. During a concurrent interview and record review on 2/16/2025 at 9:43 a.m. with the Dietary Supervisor (DS), the Refrigerator Temperature Log for February 2025 was reviewed. FSM stated he or the maintenance supervisor would fill out the column titled corrective action/comments after they addressed the temperature being out of range. DS stated he was not notified about the temperature being out of range and it is unknown if there were any corrective actions taken to address the temperatures on the dates it was out of range. During a review of the Refrigerator Temperature Log dated February 2025, it indicated to maintain the refrigerator temperature at 40 F or below during stable times and to complete corrective action column if temperatures are not in proper ranges. 055196 Page 6 of 6