Health inspection·September 2, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 reviews, the facility failed to ensure resident received treatment and care in accordance with professional standards of practice for one of four sampled residents, (Resident 1) by failing to notify physician and document interventions when Resident 1's blood pressure was elevated according to facility's policy and procedure (P&P) titled, Changes in Resident Condition.This deficient practice placed Resident 1 in incomplete assessment and documentation required per facility's P&P upon changes in condition.Findings:During a review of the admission Record, it indicated Resident 1 was admitted to the facility on [DATE] with diagnosis type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and secondary hypertension (HTN-high blood pressure).During a review of the Minimum Data Set (MDS - resident assessment tool) dated 8/1/2025, it indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 required moderate assistance to supervision 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 Blood Pressure (BP), dated 7/29/2025 at 12:24 p.m., Resident 1's BP was at 172/75 (severe high blood pressure and could be a sign of organ damage, requiring evaluation by a healthcare provider to determine the cause and appropriate treatment), on 7/29/2025 at 1:54 p.m., Resident 1's BP was 172/75, and on 7/29/2025 at 2:06 p.m., Resident 1's BP was 172/75, documented by Licensed Vocational Nurse 1 (LVN 1).During a review of Resident 1's Progress Notes dated 7/29/2025, there was no information and documentation that the physician was notified when Resident 1's BP was elevated.During an interview with LVN 1 on 9/2/2025 at 2:26 p.m., LVN 1 stated, Resident 1's BP was elevated on 7/29/2025 from around 12:00 p.m. to 2 p.m. LVN 1 stated, she did not document what interventions she provided when Resident 1's BP was elevated.During an interview with Director of Nursing (DON) on 9/2/2025 at 4:21 p.m., DON stated, residents with changes of condition, the physician should be notified, and staff should document the interventions completed, such as elevated BP.During a review of the facility's P&P titled, Changes in Resident Condition, reviewed on 1/23/2025, the P&P indicated that, The resident, attending Physician and resident representative (if resident has not capacity to make health care decisions or if resident opts to notify a designated family member) are notified when changes in condition or certain events occur. Changes in the resident status are documented by the Licensed Nurse in the SBAR or progress notes, care plan and risk meeting notes. Plan of care will be communicated to the Interdisciplinary staff. Residents Affected - Few Page 1 of 3 055540 055540 09/02/2025 Santa Monica Health Care Center 1320 20th Street Santa Monica, CA 90404

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 observation, interview, and record review, the facility failed to ensure proper sanitation and food handling practices by failing to:1. Ensure to label an open container of mayonnaise bottle with the date it was opened and use by inside one of two Refrigerator (Refrigerator 1).2. Ensure one of the two staff in the kitchen, [NAME] 1 (CK 1) properly performed hand hygiene by washing hands and changing gloves after handling food.These deficient practices had the potential to result in unsafe food management, and foodborne illness.Findings:1. During a concurrent observation of the kitchen with Dietary Supervisor (DS) on 9/2/2025 at 3:03 p.m., inside Refrigerator 1, an open bottle of mayonnaise was observed. DS stated that the container does not have a label of open date and use by date. DS stated, it should have a label of an open date and used-by date on the bottle after it's been opened.2. During an observation with [NAME] 1 on 9/2/2025 at 3:09 p.m., CK 1 was observed preparing egg sandwiches while wearing a disposable glove. After preparing the egg sandwiches, he placed the egg sandwiches onto a tray, covered with a saran wrap and placed them into Refrigerator 2, all while wearing the same glove. CK 2 then started proceeding to prepare tuna sandwiches, placing the bread onto a tray and putting the tuna spread on the bread, all while wearing the same gloves.During a follow-up interview with DS on 9/2/2022 at 3:22 p.m., DS stated, any open food contained should be labeled with an open date so that they know how long it will be good for. DS further stated, staff should follow hand hygiene protocols when preparing food, such as hand washing and changing gloves in between preparing food. Stated it puts residents at risk of infection control and food borne illnesses if staff prepared food without practicing proper hand hygiene.During a review of the facility's policy and procedure (P&P) titled, Food receiving and storage of cold foods, reviewed date 1/23/2025, the P&P indicated that, All open food items will have an open date and use-by-date per manufacturer's guidelines. 055540 Page 2 of 3 055540 09/02/2025 Santa Monica Health Care Center 1320 20th Street Santa Monica, CA 90404

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection control measure and prevention by failing to ensure the staff cleaned and sanitized shared medical equipment between each resident's use for one of four sampled residents (Resident 5) as indicated in the facility's policy and procedures (P&P) titled, Sharing of Medical Equipment.This deficient practice had the potential to result in the spread of disease and infection to other residents, visitors, and staff.Findings:During a review of the admission Record indicated Resident 5 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (loss of the ability to move in one side of the body) following nontraumatic intracerebral hemorrhage (a type of stroke that occurs when a blood vessel in the brain ruptures and bleeds into the brain tissue), hypertension (HTN-high blood pressure) and type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of the Minimum Data Set (MDS - resident assessment tool) dated 5/7/2025, indicated Resident 5's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. 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 concurrent observation and interview with Licensed Vocational Nurse 2 (LVN 2) on 9/2/2025 at 3:48 p.m., LVN 2 was observed taking the blood pressure (BP) machine from the hallway and then preceded to take Resident 5's vital signs (VS - essential measurements that indicate a person's basic physiological functions) using the blood pressure machine inside Resident 5's room. After taking Resident 5's VS, LVN 2 then placed the BP machine back in the hallway without cleaning and disinfecting the BP machine. LVN 2 was asked if he cleaned and sanitized the BP machine before and after use, LVN 2 stated, no, I forgot to clean the BP machine.During an interview with the Director of Staff and Development (DSD) on 9/2/2025 at 3:40 p.m., DSD stated, staff must clean and disinfect shared medical equipment such as BP machine for infection control and prevention.During an interview with Director of Nursing (DON) on 9/2/2025 at 4:31 p.m., DON stated, staff must clean and sanitize the BP machine before and after use to prevent any spread of infection in the facility.During a review of the facility's P&P titled, Sharing of Medical Equipment, reviewed date 1/23/2025, the P&P indicated that, It is the policy of this facility to ensure that all shared medical equipment is cleaned, disinfected, and maintained according to evidence-based infection prevention standards. Equipment shall never be used on more than one resident without proper sanitation to prevent cross-contamination, healthcare-associated infections, and to ensure compliance with CDC, CMS and facility infection control protocols. Residents Affected - Few 055540 Page 3 of 3