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 (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 6 Event ID: 055196 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 055196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marycrest Manor 10664 St. James Drive Culver City, CA 90230 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)