Health inspection·November 13, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1b. A review of Resident 64's admission Record indicated Resident 64 was admitted to the facility on [DATE], with diagnoses including displaced fracture (break in bone) in left tibia (also known as the shinbone or shank bone, is the larger, stronger, and anterior [frontal] of the two bones in the leg below the knee), and fracture of left lower leg, depression (a mood disorder that causes persistent feeling of sadness and loss of interest), and sciatica (pain, weakness, numbness, or tingling in the leg). A review of the MDS dated [DATE], indicated Resident 64's cognitive skills for daily decision-making were intact and required supervision to moderate assistance from staff for activities of daily living (ADLs- sit to lying, chair to bed transfer, toilet transfer, and walking 10 feet). A review of Resident 64's medication order indicated, oxycodone 10 milligram (mg - unit of measurement) every 3 hours as needed for severe pain. During an interview with Resident 64 on 11/11/2023 at 12:24 p.m., Resident 64 stated she was experiencing severe pain and would request pain medication per physician's order. Resident 64 stated, during the first few days of admission, LVN 3 asked her if she know the maximum dosage of oxycodone she could take in a day. Resident 64 further stated, she felt uncomfortable when LVN 3 asked her the maximum dose of Oxycodone. Resident 64 stated LVN 3 was supposed to have information of Oxycodone. Resident 64 stated, she was aware that her physician ordered that she takes Oxycodone every 3 hours as needed. Resident 64 stated, she talked to the Director of Nursing (DON) regarding the incident with LVN 3. During an interview with the DON on 11/12/2023 at 4:37 p.m., the DON stated Resident 64 was concerned about the nurses educating her on the oxycodone's maximum dosage instead of providing Resident 64 with the pain medication as per physician's order. The DON stated staff should provide residents' care with dignity and respect and to provide medications as ordered by the physician. A review of the facility's P&P titled, Resident Rights Guidelines for All Nursing Procedure, revised October 2023, indicated, To provide general guidelines for resident rights while caring for resident . staff must have appropriate in-service training on resident rights, including . resident dignity and respect . resident freedom of choice. Based on observation, interview and record review, the facility failed to ensure the resident's right to be treated and dignity and to self-determination for two of the 15 sampled residents when: 1. Licensed Vocational Nurse 3 (LVN 3) asked Resident 64 what was Oxycodone (controlled strong pain Page 1 of 47 055711 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0550 medication) the maximum dose per day. Level of Harm - Minimal harm or potential for actual harm 2. Resident 4 (female) shared a bathroom with male residents. Residents Affected - Few As a result, Resident 67 felt uncomfortable and Resident 4 felt bad and disgusted every time she had to use the bathroom. Findings: 1a. A review of Resident 4's admission Record indicated Resident 64 was admitted to the facility on [DATE], with diagnoses including dislocation of internal right hip prosthesis (when the ball of the new hip implant comes out of the socket), history of falling, and insomnia (a common sleep disorder where you may have trouble falling asleep, staying asleep, or getting good quality sleep). A review of Resident 4's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 10/8/2023, indicated Resident 4's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were intact and required supervision from staff for ADLs (toileting hygiene, shower/bathe, lower body dressing, putting on/taking off footwear, personal hygiene, and picking up object). During a concurrent observation and interview with Resident 4 on 11/11/23 at 4:58 p.m., Resident 4's room bathroom was adjoined with the next room bathroom occupied by male residents. Resident 4 stated that she constantly felt bad and disgusted every time she had to use the bathroom because she had to share the bathroom with male residents. Resident 4 stated that she often found urinals (device for collecting urine) which made her feel even worse. A review of the facility's policy and procedures (P&P) titled, Resident Rights Guidelines for All Nursing Procedure, revised October 2023 indicated, To provide general guidelines for resident rights while caring for resident . staff must have appropriate in-service training on resident rights, including . resident dignity and respect . resident freedom of choice. A review of the facility's P&P titled, Quality of Life-Homelike Environment, revised April 2023 indicated, Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. It further indicated staff shall provide person centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. 055711 Page 2 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. 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 licensed nursing staff failed to ensure that the residents and/or responsible party (RP) were informed in advance, of the risks and benefits of psychoactive medication (a drug that changes brain function and results in alterations in perception, mood, consciousness, or behavior) for one of 15 sampled residents (Resident 38). Residents Affected - Few This deficient practice violated the residents' right to make an informed decision regarding the use of psychoactive medications. Findings: A review of Resident 38's admission record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), anxiety (a feeling of fear, dread, and uneasiness. It might cause you to sweat, feel restless and tense, and have a rapid heartbeat), and encephalopathy (any disease that affects the whole brain and alters its structure or how it works, and causes changes in mental function). A review of Resident 38's Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 10/27/2023, indicated Resident 38 was moderate cognitive impairment (a condition in which people have more memory or thinking problems than other people their age) and was dependent for toileting hygiene, lower body dressing, putting on/taking off footwear, sitting to lying. It also indicated he required substantial/maximum assistance roll left and right oral hygiene, and shower/bathe self. During a concurrent interview and record review of the physician's orders with the Director of Nursing on 11/12/23 at 7:41 p.m., the DON confirmed that Resident 38 had an order of escitalopram (Lexapro - used to treat depression and anxiety. It works by helping to restore the balance of a certain natural substance (serotonin) in the brain) 10 mg to be given by mouth at night for depression manifested by verbalization of sadness but had not signed consent. Resident also had an order of buspirone (Buspar- an anxiolytic agent used for short-term treatment of generalized anxiety and second-line treatment of depression) 10 mg tabs to be given by mouth daily with no consent on file. The DON admitted that the consents had not been signed and that the facility should have a consent on file so that residents receive treatments that they are consenting to. A review of the facility's policy and procedures titled Psychotropic Medication Use Policy, revised January 2023 indicated, It is the policy of this facility that: All residents receiving psychotropic medication(s) prescribed for control of a specific behavior or manifestation of a disordered thought process shall be monitored for effectiveness of the medication and for adverse drug reactions. It further indicated the resident or designated responsible party has the right to make decisions with regard to his/her medical condition, to receive information related to the need for and the risks related to the use of psychotherapeutic drugs. The resident likewise shall be advised that he/ she has the right to accept or refuse the proposed treatment. It also indicated, the Attending Physician shall be responsible for informing the resident prior to the first use of Psychotherapeutic drug and for Verification of Informed Consent to the facility. The facility shall be responsible for documenting Verification of Informed Consent. 055711 Page 3 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to, for eight of 22 sampled residents (Resident 11, 21, 28, 29, 36, 126, 127 and 227),: 1. Inform or offer advanced directive (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) information, 2. Maintain a current copy of resident's advance directive in resident's clinical record 3. Followed up and provided additional information on advanced directive upon request. These deficient practices violated the residents' and/or the representatives' right to be fully informed of the option to formulate advanced directives and had the potential to cause conflict with health care wishes for Residents 11, 21, 28, 29, 36, 126, 127 and 227. Findings: A. During a review of Resident 127's admission Record, indicated the facility admitted Resident 127 on 11/25/2022 with diagnoses including sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), pneumonia (PNA-infection that inflames air sacs in one or both lungs which may fill with fluid) and obesity (a disorder involving excessive body fat that increases the risk of health problems). During a review of Resident 127's Minimum Data Set (MDS- a standadrdizedassessment and care screening tool) dated 10/23/2023, indicated Resident 127's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making was intact. The MDS indicated Resident 127 required moderate to maximal staff assistance with activities of daily living (ADL). During a review of Resident 127's Advance Directive Acknowledgement form, dated 11/25/2022, indicated Resident 127's representative signed the adavnced drective form and requested for additional information regarding advance directive. During a review of Resident 127's Social Service Assessment, dated 8/8/2023, the assessment indicated no advance directive, and no documented that a follow up provided to Resident 127's representative regarding the requested additional information on advance directive. During a concurrent interview and record review with the Social Serviced Director (SSD) on 11/12/2023 at 10:29 a.m., Resident 127's advanced directive was reviewed. The SSD also stated following up and providing advance directive information when requested by the resident or resident's family and documenting on the resident's medical record was important. During a review of Resident 126's admission Record, indicated the facility admitted Resident 126 on 10/26/2023 with diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue). 055711 Page 4 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 126's MDS, dated [DATE], indicated Resident 126's cognitive skill for daily decision-making was intact and moderate assistance with staff for ADLs. During a review of Resident 126's Advance Directive Acknowledgement form, dated 10/26/2023, form indicated Resident 126's representative signed that advance directive was not executed; no other information if Resident 126's representative would like to receive additional information and/or refused any additional information regarding advance directive. During a review of Resident 126's Social Service Assessment, dated 11/3/2023, the assessment indicated no advance directive, and no documented evidence that follow up was provided to Resident 126's representative if additional information regarding advance directive was needed. During a concurrent interview and record review with the SSD on 11/12/2023 at 10:29 a.m., the SSD stated upon a resident's admission, nursing should complete advance directive acknowledgment form and social service department would follow up on any needed information. The SSD also stated following up and providing advance directive information when requested by the resident or resident's family and documenting on the resident's medical record was important. A review of the facility's P&P titled, Advance Directives, revised on January 2023 indicated, Advance directives will be respected in accordance with state law and facility policy . upon admission, the resident will be provided with written information concerning the right to refuse of accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so . prior to or upon admission or a resident, the social services director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives . B. A review of Resident 21's admission Record indicated resident was admitted to the facility on [DATE], with diagnoses including chronic hepatitis C (an infection caused by a virus that attacks the liver and leads to inflammation), post-traumatic stress disorder (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), and radiculopathy (injury or damage to nerve roots in the area where they leave the spine). A review of Resident 21's MDS dated [DATE], indicated Resident 21's cognitive skills for daily decision-making were moderately impaired and required extensive assistance from staff for ADL (bed mobility, transfer, dressing, and toilet use). A Review of Resident 21's Advance Directive Acknowledgement form, dated 9/9/2023 indicated, Resident 21 signed and requested, would like to receive additional information, regarding the Advance Directive. A review of Resident 21's Progress Notes dated, 11/11/2023 indicated, the SSD met with Resident 21 to follow-up on Advance Directive information. During an interview with the SSD on 11/11/2023 at 4:45 p.m., the SSD stated she was not aware of Resident 21's request on more information regarding Advance Directive. The SSD stated she did not follow-up on Resident 21's request timely which is a residents' rights. C. A review of Resident 28's admission Record indicated Resident 28 was admitted to the facility on [DATE], with diagnoses including intervertebral disc degeneration (when the spinal disks wear 055711 Page 5 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some down), unspecified dementia (loss of cognitive functioning-thinking, remembering, and reasoning) and major depressive disorder (a mood disorder that causes persistent feeling of sadness and loss of interest). A review of Resident 28's MDS dated [DATE], indicated Resident 28's cognitive skills for daily decision-making were severely impaired and required maximal assistance from staff for ADLs (oral hygiene, lower body dressing, sit to lying and to stand and walking 10 feet). A Review of Resident 28's Advance Directive Acknowledgement form, dated 10/14/2023 indicated, Resident 28's responsible party signed and indicated, I have executed an Advance Directive, and a copy has been requested. A review of Resident 28's electronic and hard copy medical chart on 11/11/2023, indicated no Advance Directive on file for Resident 28. A review of Resident 28's Progress Notes dated 11/11/2023 at 11:40 a.m., indicated, that SSD placed a call (telephone) to patient's (responsible party) to follow up on request for a copy of Advance Directive. During an interview with the SSD on 11/11/2023 at 4:45 p.m., the SSD stated she was not aware of Resident 28's Advance Directive Acknowledgement Form dated 10/14/2023 that Resident 28 had an Advanced Directive. The SSD stated she did not follow-up on the copy of the Advance Directive timely for Resident 28 and the facility did not know what Resident 28 and responsible party's wishes were in the event that Resident 28 could no longer make decisions. D. A review of Resident 36's admission Record indicated resident was originally admitted to the facility on [DATE] and was readmitted on [DATE], with diagnoses including hemiplegia and hemiparesis (loss of the ability to move in one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting right dominant side, 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 congestive heart failure (a condition in which the heart does not pump blood as well as it should). A review of Resident 36's MDS dated [DATE], indicated Resident 36's cognitive skills for daily decision-making were moderately impaired and required moderate assistance from staff for ADLs- oral hygiene, toileting, shower/bathing, lower body dressing. A Review of Resident 36's Advance Directive Acknowledgement form, dated 10/28/2023 indicated, Resident 26's signed and indicated, I have executed an Advance Directive, and a copy has been requested. A review of Resident 36's electronic and hard copy medical chart on 11/11/2023, indicated no Advance Directive on file. A review of Resident 36's Progress Notes dated, 11/11/2023 at 11:37 a.m., indicated the SSD placed a call to Resident 36's (responsible party) to follow up on a copy of the Advance Directive. During an interview with the SSD on 11/11/2023 at 4:45 p.m., the SSD stated, she was not aware of Resident 36's Advance Directive Acknowledgement Form dated 10/28/2023 that Resident 36 had an Advanced Directive. The SSD stated she did not follow-up on the copy of the Advance Directive timely for 055711 Page 6 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 36 and the facility did not know what Resident 36's wishes were in the event that Resident 36 can no longer make decisions. D. A review of Resident 29's admission Record indicated resident was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of prostate (prostate cancer - a disease in which malignant (cancer) cells form in the tissues of the prostate), intervertebral disc degeneration, and spinal stenosis (narrowing of the spaces within the spine, which can put pressure on the nerves that travel through the spine). A review of Resident 29's MDS dated [DATE], indicated Resident 29's cognitive skills for daily decision-making were severely impaired and required moderate assistance from staff for ADLs- oral hygiene, toileting, shower/bathing, upper body dressing and personal hygiene. A Review of Resident 29's Advance Directive Acknowledgement form, dated 10/17/2023 indicated, Resident 29's responsible party signed and indicated, I have executed an Advance Directive, and a copy has been requested. A review of Resident 29's electronic and hard copy medical chart on 11/11/2023, indicated no Advance Directive on file. A review of Resident 29's Progress Notes dated, 11/11/2023 at 11:23 a.m., indicated, the SSD placed a call to patient's (responsible party) to follow up on request of Advance Directive. During an interview with the SSD on 11/11/2023 at 4:45 p.m., the SSD stated she was not aware of Resident 29's Advance Directive Acknowledgement Form dated 10/16/2023 that Resident 29 had an Advanced Directive. The SSD stated she did not follow-up on the copy of the Advance Directive timely for Resident 29 and that the facility did not know what Resident 29 and responsible party's wishes were in the event that Resident 29 could no longer make decisions. A review of the facility's P&P titled, Advance Directives, revised 1/2023 indicated, Advance directives will be respected in accordance with state law and facility policy . upon admission, the resident will be provided with written information concerning the right to refuse of accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so . prior to or upon admission or a resident, the social services director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives . E. A review of Resident 11's admission record indicated Resident 11 was admitted to the facility on [DATE] with diagnoses including hypothyroidism (underactive thyroid [a small, butterfly-shaped gland in the front of the neck]) is when the thyroid gland does not produce adequate thyroid hormones to meet the body's needs), overactive bladder (OAB-causes a frequent and sudden urge to urinate that may be difficult to control), and hypertension (high blood pressure). A review of Resident 11's MDS dated [DATE], indicated Resident 11 was cognitively intact and required supervision assistance for eating, oral hygiene, personal hygiene. Resident 11 required partial/maximum staff assistance for upper body dressing. The MDS further indicated that Resident 11 required substantial/maximum assistance for putting on/taking off footwear, roll left and right, sit to lying, and sit to stand. 055711 Page 7 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some F. A review of Resident 227's admission record indicated Resident 227 was admitted to the facility on [DATE] with diagnoses including syncope and collapse (also called fainting or passing out. It most often occurs when blood pressure is too low (a condition called hypotension) and the heart doesn't pump enough oxygen to the brain. It can be harmless or a symptom of an underlying medical condition), chronic obstructive pulmonary disease (COPD, refers to a group of diseases that cause airflow blockage and breathing-related problems), and paroxysmal atrial fibrillation (rapid and erratic heart rate). A review of Resident 227's MDS dated [DATE], indicated Resident 227 had moderate cognitive impairment. The MDS indicated Resident 227 required partial/moderate staff assistance for walking 10 feet, , one step curb. Resident 227 required supervision or touch assistance for toilet hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, and toilet transfer. During a concurrent interview and record review with the SSD on 11/11/23 at 5:01 p.m., Resident 227's medical chart was reviewed and did not have an Advance The SSD stated that AD reflected and indicated who was Resident 227's next of kin. The SSD confirmed and stated that it was Resident 227's right to have an advanced directive on file and that not having them on file would result in Resident 227 receiving services against the resident's wishes. A review of the facility's P&P titled Advance Directives, revised 1/2023 indicated Advance directives will be respected in accordance with state law and facility policy. The P&P Interpretation and Implementation indicated the following: 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 2. Written information will include a description of the facility's policies to implement advance directives and applicable state law. 3. If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative. 4. If the resident becomes able to receive and understand this information later, he or she will be provided with the same written materials as described above, even if his or her legal representative has already been given the information. 5. Each resident will also be informed that the facility's policies do not condition the provision of care or discriminate against an individual based on whether or not the individual has executed an advance directive. 6. Prior to or upon admission of a resident, the social services director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. 7. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 8. If the resident indicates that he or she has not established advance directives, the facility 055711 Page 8 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0578 staff will offer assistance in establishing advance directives. Level of Harm - Minimal harm or potential for actual harm a. The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision. Residents Affected - Some b. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance. 9. The attending physician will provide information to the resident and legal representative regarding the resident's health status, treatment options and expected outcomes during the development of the initial comprehensive assessment and care plan. 10. The plan of care for each resident will be consistent with his or her documented treatment preferences and/ or advance directive. 11. The resident has the right to refuse treatment, whether or not he or she has an advance directive. A resident will not be treated against his or her own wishes. Residents who refuse treatment will not be transferred to another facility unless all other criteria for transfer are met. 12. Depending on state requirements, the legal representative may also have the right to refuse or forego treatment. 055711 Page 9 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During a review of Resident 7's admission Record, indicated the facility originally admitted Resident 7 on 9/3/2023 and was re-admitted on [DATE] with diagnoses including fracture of bilateral humerus (a break, crack or crush injury of the bone in both arms), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body). Residents Affected - Some During a review of Resident 7's Safety Device/Mobility Device Assessment, dated 9/3/2023, assessment indicated Resident 7was recommended by the interdisciplinary team (IDT) to have both sides 1/4 side rails for mobility device, improve function, improve posture, grab bar, and repositioning. During a review of Resident 7's Order Summary Report, dated 9/15/2023. The Order Summary Report indicated Resident 7 had an order for one fourth (1/4) side rails (SR) up while in bed as enabler for mobility and 1/4 SR up while in bed for safe turning and repositioning. During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 7's cognitive skill for daily decision-making was intact and with one-person physical assistance for activities of daily livings (ADLsbed mobility, dressing, toilet use, and personal hygiene). During an observation on 11/10/2023 at 12:05 p.m., Resident 7 was observed laying in bed with bilateral upper SR up. During an observation on 11/11/2023 at 9:30 a.m., Resident 7 was observed laying in bed with bilateral upper SR up. During an interview with Registered Nurse 3 (RN 3) on 11/12/2023 at 4:57 p.m., RN 3 stated that the SR order should be ordered as bilateral or both 1/4 SR, instead of only 1/4 SR. RN 3 stated and validated that 1/4 SR order means that resident only needs 1 side rail up, either on left or right of upper or bottom SR. RN 3 also verified that all residents that has an order for SR when in bed as either enabler or turn/repositioning needs the bilateral upper SR up for safety. During a review of Resident 16's admission Record, indicated the facility admitted Resident 16 on 9/13/2023 with diagnoses including osteoporosis (a condition in which bones become weak and brittle), Alzheimer's disease (a progressing brain disorder that destroys memory and other important mental function) and dementia (a chronic or persistent disorder of the mental processes caused by brain disease). During a review of Resident 16's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 10/5/2023, the MDS indicated Resident 16's cognitive skill for daily decision-making was severely impaired and with moderate to maximal assistance for activities of daily livings (ADLs- bed mobility, dressing, toilet use, and personal hygiene). MDS also indicated Resident 16 was using bed rail restraints daily. During a review of Resident 16's Order Summary Report, dated 9/13/2023. The Order Summary Report indicated Resident 16 had an order for one fourth (1/4) side rails (SR) up while in bed as enabler for mobility and 1/4 SR up while in bed for safe turning and repositioning. 055711 Page 10 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0604 Level of Harm - Minimal harm or potential for actual harm During an observation on 11/10/2023 at 11:40 a.m., Resident 16 was observed laying in bed with bilateral upper SR up. During an observation on 11/11/2023 at 9:23 a.m., Resident 16 was observed laying in bed with bilateral upper SR up. Residents Affected - Some During an interview with RN 3 on 11/12/2023 at 4:57 p.m., RN 3 stated that the SR order should be ordered as bilateral or both 1/4 SR, instead of only 1/4 SR. RN 3 stated and validated that 1/4 SR order means that resident only needs 1 side rail up, either on left or right of upper or bottom SR. RN 3 also verified that all residents that has an order for SR when in bed as either enabler or turn/repositioning needs the bilateral upper SR up for safety. During a review of Resident 27's admission Record, indicated the facility originally admitted Resident 27 on 11/29/2022 and was re-admitted on [DATE] with diagnoses including COVID-19 (Coronavirus- a deadly respiratory disease transmitted from person to person), hypertension (HTN - elevated blood pressure) and dementia (a chronic or persistent disorder of the mental processes caused by brain disease). During a review of Resident 27's MDS, dated [DATE], the MDS indicated Resident 27's cognitive skill for daily decision-making was severely impaired and with maximal assistance for ADLs. During a review of Resident 27's Order Summary Report, dated 10/31/2023. The Order Summary Report indicated Resident 27 had an order for one fourth (1/4) side rails (SR) up while in bed as enabler for mobility and 1/4 SR up while in bed for safe turning and repositioning. During a review of Resident 27's Safety Device/Mobility Device Assessment, dated 10/31/2023, assessment indicated Resident 27 was recommended by the IDT to have both sides 1/4 side rails for mobility device, improve function, improve posture, grab bar, and repositioning. During an observation on 11/10/2023 at 12:01 p.m., Resident 27 was observed laying in bed with bilateral upper SR up. During an observation on 11/11/2023 at 9:24 a.m., Resident 27 was observed laying in bed with bilateral upper SR up. During an interview with RN 3 on 11/12/2023 at 4:57 p.m., RN 3 stated that the SR order should be ordered as bilateral or both 1/4 SR, instead of only 1/4 SR. RN 3 stated and validated that 1/4 SR order means that resident only needs 1 side rail up, either on left or right of upper or bottom SR. RN 3 also verified that all residents that has an order for SR when in bed as either enabler or turn/repositioning needs the bilateral upper SR up for safety. During a review of Resident 52's admission Record, indicated the facility admitted Resident 52 on 10/27/2023 with diagnoses including neoplasm (a new and abnormal growth of tissues) in the bladder and vaginal area and asthma (respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing). During a review of Resident 52's Order Summary Report, dated 10/27/2023. The Order Summary Report indicated Resident 52 had an order for 1/4 SR up while in bed as enabler for mobility and 1/4 SR up while in bed for safe turning and repositioning. 055711 Page 11 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 52's Safety Device/Mobility Device Assessment, dated 10/27/2023, assessment indicated Resident 52 was recommended by the interdisciplinary team (IDT) to have both sides 1/4 side rails for mobility device, improve function, improve posture, grab bar, and repositioning. During a review of Resident 52's MDS, dated [DATE], the MDS indicated Resident 52's cognitive skill for daily decision-making was intact and with some supervision with staff for ADLs. MDS also indicated Resident 16 was using bed rail restraints daily. During an observation on 11/10/2023 at 12:05 p.m., Resident 52 was observed laying in bed with bilateral upper SR up. During an observation on 11/11/2023 at 9:30 a.m., Resident 52 was observed laying in bed with bilateral upper SR up. During an interview with RN 3 on 11/12/2023 at 4:57 p.m., RN 3 stated that the SR order should be ordered as bilateral or both 1/4 SR, instead of only 1/4 SR. RN 3 stated and validated that 1/4 SR order means that resident only needs 1 side rail up, either on left or right of upper or bottom SR. RN 3 also verified that all residents that has an order for SR when in bed as either enabler or turn/repositioning needs the bilateral upper SR up for safety. During a review of Resident 57's admission Record, indicated the facility admitted Resident 57 on 10/23/2023 with diagnoses including osteoporosis, hemiplegia and hemiparesis. During a review of Resident 57's MDS, dated [DATE], the MDS indicated Resident 57's cognitive skill for daily decision-making was moderately impaired and with moderate assistance with staff for ADLs. MDS also indicated Resident 57 was using bed rail restraints daily. During a review of Resident 57's Order Summary Report, dated 10/23/2023. The Order Summary Report indicated Resident 57 had an order for 1/4 SR up while in bed for safe turning and repositioning. During a review of Resident 57's Safety Device/Mobility Device Assessment, dated 11/11/2023, assessment indicated Resident 57 was recommended by the IDT to have both sides 1/4 SR for mobility device, improve function, improve posture, grab bar, and repositioning. During an observation on 11/10/2023 at 12:50 p.m., Resident 57 was observed laying in bed with bilateral upper SR up. During an observation on 11/11/2023 at 9:24 a.m., Resident 57 was observed laying in bed with bilateral upper SR up. During an interview with RN 3 on 11/12/2023 at 4:57 p.m., RN 3 stated that the SR order should be ordered as bilateral or both 1/4 SR, instead of only 1/4 SR. RN 3 stated and validated that 1/4 SR order means that resident only needs 1 side rail up, either on left or right of upper or bottom SR. RN 3 also verified that all residents that has an order for SR when in bed as either enabler or turn/repositioning needs the bilateral upper SR up for safety. During a review of Resident 127's admission Record, indicated the facility admitted Resident 127 on 11/25/2022 with diagnoses including sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), pneumonia (PNA-infection that 055711 Page 12 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0604 Level of Harm - Minimal harm or potential for actual harm inflames air sacs in one or both lungs which may fill with fluid) and obesity (a disorder involving excessive body fat that increases the risk of health problems). During a review of Resident 127's MDS, dated [DATE], the MDS indicated Resident 127's cognitive skill for daily decision-making was intact and moderate to maximal assistance with staff for ADLs. Residents Affected - Some During a review of Resident 127's Order Summary Report, dated 11/25/2023. The Order Summary Report indicated Resident 127 had an order for 1/4 SR up while in bed as enabler for mobility and 1/4 SR up while in bed for safe turning and repositioning. During a review of Resident 127's Safety Device/Mobility Device Assessment, dated 10/18/2023, assessment indicated Resident 127 was recommended by the IDT to have both sides 1/4 SR for mobility device, improve function, improve posture, grab bar, and repositioning. During an observation on 11/10/2023 at 12:53 p.m., Resident 127 was observed laying in bed with bilateral upper SR up. During an observation on 11/11/2023 at 9:26 a.m., Resident 127 was observed laying in bed with bilateral upper SR up. During an interview with RN 3 on 11/12/2023 at 4:57 p.m., RN 3 stated that the SR order should be ordered as bilateral or both 1/4 SR, instead of only 1/4 SR. RN 3 stated and validated that 1/4 SR order means that resident only needs 1 side rail up, either on left or right of upper or bottom SR. RN 3 also verified that all residents that has an order for SR when in bed as either enabler or turn/repositioning needs the bilateral upper SR up for safety. Based on observation, interview, and record review, the facility failed to ensure that 10 of 10 sampled residents (Residents 6, 28, 38, 229, 7, 16, 27, 52, 57, and 127) were free from physical restraint by a. failing to ensure the use of side rails (SR) are properly assessed in the Minimum Data Set (MDS - a standardized assessment and care-screening tool). b. failing to ensure the physician's order for one fourth (1/4) side rails (SR) up as enablers for mobility were applied. These deficient practices had the potential to result in entrapment and injury and residents not being treated with respect and dignity with the use of restraints. Findings: A. A review of Resident 6's admission Record indicated resident was admitted to the facility on [DATE], with diagnoses including chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure), acute respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), and type II diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]). A review of Resident 6' s MDS dated [DATE], indicated Resident 6's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were intact and 055711 Page 13 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some required maximal to dependence from staff for activities of daily living (ADLs- oral hygiene, toileting, shower/bathing, personal hygiene). The MDS also indicated, Resident 6 is on physical restraints using bed rails daily. A review of Resident 6's Physician's Order Summary Report, dated 11/10/2023 indicated, 1/4 SR (side rail) up while in bed as enabler for mobility and 1/4 SR up while in bed for safe turning and repositioning. A review of Resident 6's Safety Device/Mobility Device assessment dated [DATE] indicated, Resident 6 was observed to be able to use side rail for bed mobility with recommendations to use both sides, 1/4 side rails for mobility device. A review of Resident 6's care plan for 1/4 bed SR as enabler to assist with bed mobility, initiated on 10/29/2023 had a goal of will continue to utilize the 1/4 SR to assist with turning, repositioning, or transfer. During an observation with Resident 6 on 11/10/2023 at 11:36 a.m., Resident was observed with bilateral upper siderails up. B. A review of Resident 28's admission Record indicated resident was admitted to the facility on [DATE], with diagnoses including intervertebral disc degeneration (when the spinal disks wear down), unspecified dementia (loss of cognitive functioning-thinking, remembering, and reasoning) and major depressive disorder (a mood disorder that causes persistent feeling of sadness and loss of interest). A review of Resident 28's MDS dated [DATE], indicated Resident 28's cognitive skills for daily decision-making were severely impaired and required maximal assistance from staff for ADLs- oral hygiene, lower body dressing, sit to lying and to stand and walking 10 feet. The MDS also indicated, Resident 28 is on physical restraints using bed rails daily. A review of Resident 28's Physician's Order Summary Report, dated 10/13/2023 indicated, 1/4 SR up while in bed as enabler for mobility and 1/4 SR up while in bed for safe turning and repositioning. A review of Resident 28's Safety Device/Mobility Device Assessment, dated 10/13/2023 indicated, Resident 28 was observed to be able to use side rail for bed mobility with recommendations to use both sides, 1/4 side rails for mobility device. A review of Resident 28's care plan for 1/4 bed SR as enabler to assist with bed mobility, initiated on 10/13/2023 had a goal of will continue to utilize the 1/4 SR to assist with turning, repositioning, or transfer. During an observation with Resident 6 on 11/10/2023 at 11:12 a.m., Resident 28 was observed with bilateral upper siderails up. C. A review of Resident 38's admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including severe sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs) metabolic encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood) and primary osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down). 055711 Page 14 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 38's MDS dated [DATE], indicated Resident 38's skills for daily decision-making were moderately impaired and required maximal assistance to dependent from staff for ADLs- roll left and right, sit to lying, lying to sitting and car transfer. The MDS also indicated that Resident 38 is on physical restraints using bed rails daily. A review of Resident 38's Physician's Order Summary Report, dated 10/23/2023 indicated, 1/4 SR up while in bed as enabler for mobility and 1/4 SR up while in bed for safe turning and repositioning. A review of Resident 38's Safety Device/Mobility Device Assessment, dated 10/23/2023 indicated, Resident 38 was observed to be able to use side rail for bed mobility with recommendations to use both sides, 1/4 side rails for mobility device. A review of Resident 38's care plan for 1/4 bed SR as enabler to assist with bed mobility, initiated on 10/23/2023 had a goal of will continue to utilize the 1/4 SR to assist with turning, repositioning, or transfer. During an observation with Resident 38 on 11/10/2023 at 11:28 a.m., Resident 38 was observed with bilateral upper siderails up. During an interview with Director of Nursing (DON), on 11/12/2023 at 4:51 p.m., DON stated, they utilize bed rails up as enablers for mobility with physician's order of 1/4 SR up. DON stated, the nurse's safety device/mobility device assessment does not correlate together with physician's order as indicated 1/4 SR up, and the safety device/mobility device assessment indicated both sides, bed SR up. DON stated, 1/4 side rails is not the same as both sides side rails up. DON stated, the facility did not follow physician's order. A review of the facility's policy and procedures (P&P) titled, Use of Side Rails, revised January 2023 indicated, The purposes of these guidelines are to ensure the sage use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms . side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents. D. A review of Resident 229's admission record indicated Resident 229 was admitted to the facility on [DATE] with diagnoses including hypertensive heart disease with heart failure (refers to heart problems . Without appropriate blood pressure control, the heart can weaken over time and heart failure may develop) malignant neoplasm of prostate (Prostate cancer is cancer that occurs in the prostate. The prostate is a small walnut-shaped gland in males that produces the seminal fluid), and encephalopathy (any disease that affects the whole brain and alters its structure or how it works and causes changes in mental function). A review of Resident 229's history and physical (the most formal and complete assessment of the patient and the problem. Physicians' documentation are produce through the interview with the patient, the physical exam, and the summary of the testing either obtained or pending) dated 10/5/2023 indicated, Resident 229 had the capacity to understand and make decisions. During an observation of Resident 229 on 11/10/2023 at 12:13 p.m., bilateral side rails were elevated. A review of the physician's order with an effective date of 11/12/2023, indicated 1/4 side rails up 055711 Page 15 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some while in bed as enabler. Another order with the same effective date indicated, 1/4 side rails up while in bed used for safe turning and repositioning. During a concurrent interview and record review of Resident 229's orders on 11/12/23 5:15 p.m., RN 3 stated 1/4 is having one side rail up instead of two. She stated that having more side rails elevated would constitute a restraint (a measure or condition that keeps someone or something under control or within limits decisions are made within the financial restraints of the budget). A review of the facility's P & P titled Use of Side Rails, revised January 2023 indicated, the purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. It indicated some general guidelines which included: 1. Side rails are considered a restraint when they are used to limit the. resident's freedom of movement (prevent the resident from leaving his/her bed). (Note: The side rails may have the effect of restraining one individual but not another, depending on the individual resident's condition and circumstances.) 2. Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents. 3. An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: a. Bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails; and d. That the bed's dimensions are appropriate for the resident's size and weight. 055711 Page 16 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

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** D. During a review of Resident 16's admission Record, indicated the facility admitted Resident 16 on 9/13/2023 with diagnoses including osteoporosis (a condition in which bones become weak and brittle), Alzheimer's disease (a progressing brain disorder that destroys memory and other important mental function) and dementia. Residents Affected - Some During a review of Resident 16's MDS dated [DATE], the MDS indicated Resident 16's cognitive skill for daily decision-making was severely impaired and with moderate to maximal assistance for ADLs- bed mobility, dressing, toilet use, and personal hygiene. MDS also indicated Resident 16 was using bed rail restraints daily. During a review of Resident 16's Order Summary Report, dated 9/13/2023. The Order Summary Report indicated Resident 16 had an order for 1/4 SR up while in bed as enabler for mobility and 1/4 SR up while in bed for safe turning and repositioning. During an interview with the MDSN 2 on 11/11/2023 at 3:30 p.m., MDSN 2 stated and verified that there were no residents in the facility currently using some type of restraint. MDSN 2 stated that since the 1/4 SR are being used as enabler and for safe turning and repositioning for residents, it should not be triggered under the restraints and alarms in the MDS. A review of facility's policy and procedure (P&P), titled, Resident Assessment Instrument, revised 9/2023, P&P indicated that facility will complete a comprehensive assessment that will help staff to plan care that allows the resident to reach his/her highest practicable level of functioning. A review of facility's P&P, titled, Use of Side Rails, revised on 9/2023, P&P indicated that facility would ensure safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. P&P also indicated that physical restraints are defined by the Centers for Medicate and Medicaid Services (CMS) as any manual method or physical device or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. E. During a review of Resident 52's admission Record, indicated the facility admitted Resident 57 on 10/27/2023 with diagnoses including neoplasm (a new and abnormal growth of tissues) in the bladder and vaginal area and asthma (respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing). During a review of Resident 52's MDS, dated [DATE], the MDS indicated Resident 52's cognitive skill for daily decision-making was intact and with some supervision with staff for ADLs. MDS also indicated Resident 16 was using bed rail restraints daily. During a review of Resident 52's Order Summary Report, dated 10/27/2023. The Order Summary Report indicated Resident 52 had an order for 1/4 SR up while in bed as enabler for mobility and 1/4 SR up while in bed for safe turning and repositioning. During a review of Resident 52's Safety Device/Mobility Device Assessment, dated 10/27/2023, assessment indicated Resident 52 was recommended by the interdisciplinary team (IDT) to have both sides 1/4 side rails for mobility device, improve function, improve posture, grab bar, and repositioning. 055711 Page 17 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with the MDSN 2 on 11/11/2023 at 3:30 p.m., MDSN 2 stated and verified that there were no residents in the facility currently using some type of restraint. MDSN 2 stated that since the 1/4 SR are being used as enabler and for safe turning and repositioning for residents, it should not be triggered under the restraints and alarms in the MDS. A review of facility's P&P, titled, Resident Assessment Instrument, revised 9/2023, P&P indicated that facility will complete a comprehensive assessment that will help staff to plan care that allows the resident to reach his/her highest practicable level of functioning. A review of facility's P&P, titled, Use of Side Rails, revised on 9/2023, P&P indicated that facility would ensure safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. P&P also indicated that physical restraints are defined by the CMS as any manual method or physical device or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. F. During a review of Resident 57's admission Record, indicated the facility admitted Resident 57 on 10/23/2023 with diagnoses including osteoporosis, hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body). During a review of Resident 57's MDS, dated [DATE], the MDS indicated Resident 57's cognitive skill for daily decision-making was moderately impaired and with moderate assistance with staff for ADLs. MDS also indicated Resident 57 was using bed rail restraints daily. During a review of Resident 57's Order Summary Report, dated 10/23/2023. The Order Summary Report indicated Resident 57 had an order for 1/4 SR up while in bed for safe turning and repositioning. During a review of Resident 57's Safety Device/Mobility Device Assessment, dated 11/11/2023, assessment indicated Resident 57 was recommended by the IDT to have both sides 1/4 SR for mobility device, improve function, improve posture, grab bar, and repositioning. During an interview with the MDSN 2 on 11/11/2023 at 3:30 p.m., MDSN 2 stated and verified that there were no residents in the facility currently using some type of restraint. MDSN 2 stated that since the 1/4 SR are being used as enabler and for safe turning and repositioning for residents, it should not be triggered under the restraints and alarms in the MDS. A review of facility's P&P, titled, Resident Assessment Instrument, revised 9/2023, P&P indicated that facility will complete a comprehensive assessment that will help staff to plan care that allows the resident to reach his/her highest practicable level of functioning. A review of facility's P&P, titled, Use of Side Rails, revised on 9/2023, P&P indicated that facility would ensure safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. P&P also indicated that physical restraints are defined by the CMS as any manual method or physical device or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Based on interview and record review, the facility failed to ensure that a preadmission screening assessment was done for a resident who was diagnosed with a mental illness prior to admission in the 055711 Page 18 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0641 facility for one of one sampled resident (Resident 21). Level of Harm - Minimal harm or potential for actual harm This deficient practice had the potential for not receiving the necessary and appropriate psychiatric (relating to mental illness or its treatment) level of treatment and evaluation in the facility. Residents Affected - Some Cross Reference: F645. Findings: A review of Resident 21's admission Record indicated Resident 21 was admitted to the facility on [DATE], with diagnoses including chronic hepatitis C (an infection caused by a virus that attacks the liver and leads to inflammation), post-traumatic stress disorder (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), and radiculopathy (injury or damage to nerve roots in the area where they leave the spine). A review of Resident 21's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 9/13/2023, indicated Resident 21's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were moderately impaired and required extensive assistance from staff for activities of daily living (ADLs- bed mobility, transfer, dressing, and toilet use). A review of Resident 21's Preadmission Screening and Resident Review (PASARR) indicated, the PASARR screening was completed on 11/11/2023. During an interview with the Director of Nursing (DON) on 11/12/2023 at 3:57 p.m., DON stated PASARR was to be completed within 24 hours of admission/re-admission or prior to admission. The DON stated Resident 21's PASARR screening was not completed timely. A review of the facility's policy and procedures (P&P) titled, Preadmission Screening & Resident Review (PASARR), revised on May 2023 indicated, PASARR requires that all applicants . to be evaluated for a serious mental disorder and/or intellectual disability . the facility will obtain/complete a Preadmission Screening and Resident Review timely . pre-admit and date of PASARR should be the same day of admit as stated above. DON or Registered Nurse (RN) will complete the PASARR before admitting a resident from home or senior living facilities or on admission date. 055711 Page 19 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 that a preadmission screening assessment was completed for one of threee sampled residents (Resident 21), who was diagnosed with a mental illness prior to admission in the facility. Residents Affected - Few This deficient practice had the potential for Resident 21 not receiving the necessary and appropriate psychiatric (relating to mental illness or its treatment) level of treatment and evaluation in the facility. Cross Reference: F641. Findings: A review of Resident 21's admission Record indicated Resident 21 was admitted to the facility on [DATE], with diagnoses including chronic hepatitis C (an infection caused by a virus that attacks the liver and leads to inflammation), post-traumatic stress disorder (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), and radiculopathy (injury or damage to nerve roots in the area where they leave the spine). A review of Resident 21's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 9/13/2023, indicated Resident 21's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were moderately impaired and required extensive assistance from staff for activities of daily living (ADLs- bed mobility, transfer, dressing, and toilet use). A review of Resident 21's Preadmission Screening and Resident Review (PASARR) indicated, the PASARR screening was completed on 11/11/2023. During an interview with the Director of Nursing (DON), on 11/12/2023 at 3:57 p.m., the DON stated PASARR was to be completed within 24 hours of admission/re-admission or prior to admission. The DON stated Resident 21's PASARR screening was not completed timely. A review of the facility's policy and procedures (P&P) titled, Preadmission Screening & Resident Review (PASARR), revised on May 2023 indicated, PASARR requires that all applicants . to be evaluated for a serious mental disorder and/or intellectual disability . the facility will obtain/complete a Preadmission Screening and Resident Review timely . pre-admit and date of PASARR should be the same day of admit as stated above. DON or Registered Nurse (RN) will complete the PASARR before admitting a resident from home or senior living facilities or on admission date. 055711 Page 20 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive care plan that met the care/services based on the resident's individual assessed needs for four of 35 sampled residents (Residents 6, 16, 28 and 38) by failing to ensure: 1. Comprehensive care plan was developed and implemented for Resident 16's levetiracetam (medication to treat seizure [a sudden, uncontrolled electrical disturbance in the brain]) use. 2. Residents 6, 28 and 38 had the proper care plan for bed side rails per physician order. These deficient practices had the potential to result negative impact on Residents 6, 16, 28 and 38's health and safety, as well as the quality of care and services received. Findings: 1. A review of Resident 16's admission Record, indicated the facility admitted Resident 16 on 9/13/2023 with diagnoses including osteoporosis (a condition in which bones become weak and brittle), Alzheimer's disease (a progressing brain disorder that destroys memory and other important mental function) and dementia (a chronic or persistent disorder of the mental processes caused by brain disease). A review of Resident 16's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 10/5/2023, the MDS indicated Resident 16's cognitive skill for daily decision-making was severely impaired and with moderate to maximal assistance for activities of daily livings (ADLs- bed mobility, dressing, toilet use, and personal hygiene). A review of Resident 16's Order Summary Report, dated 9/13/2023 indicated Resident 16 had an order for levetiracetam 500 milligram (mg) by mouth two times a day for seizure. During a concurrent record review and interview with the Director of Nursing (DON), on 11/12/2023 at 7:27 p.m., Resident 16' s chart was reviewed. Resident 16's chart indicated missing care plan for levetiracetam use. DON verified and stated that Resident 16 should have a care plan for levetiracetam use. A review of the facility's policy and procedures (P&P) titled, Care Plans - Comprehensive, revised September 2023 indicated, An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident . care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. 2a. A review of Resident 6's admission Record indicated Rresident 6 was admitted to the facility on [DATE], with diagnoses including chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure), acute respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), and type II diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]). 055711 Page 21 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 6's MDS dated [DATE], indicated Resident 6's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were intact and required maximal to dependence from staff for activities of daily living (ADLs- oral hygiene, toileting, shower/bathing, personal hygiene). The same MDS further indicated, Resident 6 was on physical restraints using bed rails daily. A review of Resident 6's Physician's Order Summary Report, dated 11/10/2023 indicated, 1/4 SR (Side rail) up while in bed as enabler for mobility and 1/4 SR up while in bed for safe turning and repositioning. A review of Resident 6's Safety Device/Mobility Device assessment dated [DATE] indicated, Resident 6 was observed to be able to use side rail for bed mobility with recommendations to use both sides, 1/4 side rails for mobility device. A review of Resident 6's care plan for 1/4 bed SR as enabler to assist with bed mobility, initiated on 10/29/2023 had a goal of will continue to utilize the 1/4 SR to assist with turning, repositioning, or transfer. During an observation with Resident 6 on 11/10/2023 at 11:36 a.m., Resident was observed with bilateral upper siderails up. 2b. A review of Resident 28's admission Record indicated Resident 28 was admitted to the facility on [DATE], with diagnoses including intervertebral disc degeneration (when the spinal disks wear down), unspecified dementia (loss of cognitive functioning-thinking, remembering, and reasoning) and major depressive disorder (a mood disorder that causes persistent feeling of sadness and loss of interest). A review of Resident 28's MDS dated [DATE], indicated Resident 28's cognitive skills for daily decision-making were severely impaired and required maximal assistance from staff for ADLs- oral hygiene, lower body dressing, sit to lying and to stand and walking 10 feet. The same MDS further indicated, Resident 28 was on physical restraints using bed rails daily. A review of Resident 28's Physician's Order Summary Report, dated 10/13/2023 indicated, 1/4 SR up while in bed as enabler for mobility and 1/4 SR up while in bed for safe turning and repositioning. A review of Resident 28's Safety Device/Mobility Device Assessment, dated 10/13/2023 indicated, Resident 28 was observed to be able to use side rail for bed mobility with recommendations to use both sides, 1/4 side rails for mobility device. A review of Resident 28's care plan for 1/4 bed SR as enabler to assist with bed mobility, initiated on 10/13/2023 had a goal of will continue to utilize the 1/4 SR to assist with turning, repositioning, or transfer. During an observation with Resident 6 on 11/10/2023 at 11:12 a.m., Resident 28 was observed with bilateral upper siderails up. 2c. A review of Resident 38's admission record indicated the Resident 38 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including severe sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues 055711 Page 22 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and organs) metabolic encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood) and primary osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down). A review of the MDS dated [DATE], indicated Resident 38's skills for daily decision-making were moderately impaired and required maximal assistance to dependent from staff for ADLs- roll left and right, sit to lying, lying to sitting and car transfer. The MDS also indicated that Resident 38 is on physical restraints using bed rails daily. A review of Resident 38's Physician's Order Summary Report, dated 10/23/2023 indicated, 1/4 SR up while in bed as enabler for mobility and 1/4 SR up while in bed for safe turning and repositioning. A review of Resident 38's Safety Device/Mobility Device Assessment, dated 10/23/2023 indicated, Resident 38 was observed to be able to use side rail for bed mobility with recommendations to use both sides, 1/4 side rails for mobility device. A review of Resident 38's care plan for 1/4 bed SR as enabler to assist with bed mobility, initiated on 10/23/2023 had a goal of will continue to utilize the 1/4 SR to assist with turning, repositioning, or transfer. During an observation with Resident 38 on 11/10/2023 at 11:28 a.m., Resident 38 was observed with bilateral upper siderails up. During an interview with DON on 11/12/2023 at 4:51 p.m., DON stated, they utilize bed rails up as enablers for mobility with physician's order of 1/4 SR up. DON stated, the nurse's safety device/mobility device assessment does not correlate together with physician's order as indicated 1/4 SR up, and the safety device/mobility device assessment indicated both sides, bed SR up. The DON further stated, 1/4 side rails was not the same as both sides side rails up. DON stated, the facility did not follow physician's order as well as did not implement the care plan's interventions for use of side rails. A review of the facility's P&P titled, Care Plans - Comprehensive, revised September 2023 indicated, An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident . care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. 055711 Page 23 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of 22 sampled residents (Resident 9) psychoactive medication clonazepam (klonopin- a long-acting benzodiazepine with intermediate onset commonly used to treat panic disorders, severe anxiety, and seizures) 1. Was necessary to treat a specific diagnosis and documented condition. 2. Pharmacist recommendations were followed. This deficient practice had the potential to place Resident 9 at risk of receiving unnecessary medication. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including essential hypertension (high blood pressure that is multi-factorial and doesn't have one distinct cause with above-normal blood pressure is typically anything over 120/80), malignant neoplasm of prostate (Prostate cancer is cancer that occurs in the prostate. The prostate is a small walnut-shaped gland in males that produces the seminal fluid), and radiculopathy, lumber region (an inflammation of a nerve root in the lower back, which causes symptoms of pain or irritation in the back and down the legs). A review of Resident 9's history and physical (the most formal and complete assessment of the patient and the problem. Physicians documentation are produce through the interview with the patient, the physical exam, and the summary of the testing either obtained or pending) dated 10/16.2023 indicated, Resident 9 had the capacity to understand and make decisions. During an interview with Resident 9 on 11/10/2023 at 11:46 a.m., Resident 9 stated that he was unable to sleep well at night because his roommate coughs throughout the night. He stated that he had made the staff, the Director of Nursing (DON) aware about these issues and was offered a room change. A review of the physician's order dated 11/10/2023 indicated clonazepam tablet 0.5 mg tablet by mouth at bedtime for anxiety manifested by inability to sleep. During a concurrent interview and record review with the DON on 11/12/23 at 11:44 a.m., the DON stated that whenever a resident is having a hard time sleeping, a room change is offered if it is because of environmental factors. If disturbance not due to environmental factors, then routines such as set times for sleeping then eventually sleep medications are added. The DON confirmed and stated that Resident 9 did not have a diagnosis for anxiety. He stated that having a diagnosis for ordered medications especially psychoactive medications to ensure that the resident was receiving treatments for a condition that had been diagnosed. A review of the facility's policy and procedures titled Psychotropic Medication Use Policy, revised January 2023 indicated, It is the policy of this facility that: All residents receiving psychotropic medication(s) prescribed for control of a specific behavior or 055711 Page 24 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0657 Level of Harm - Minimal harm or potential for actual harm manifestation of a disordered thought process shall be monitored for effectiveness of the medication and for adverse drug reactions. The same policy further indicated the resident or designated responsible party has the right to make decisions with regard to his/her medical condition, to receive information related to the need for and the risks related to the use of psychotherapeutic drugs. Residents Affected - Few 055711 Page 25 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. A review of Resident 57's admission Record, indicated the facility admitted Resident 57 on 10/23/2023 with diagnoses including osteoporosis (a condition in which bones become weak and brittle), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body). Residents Affected - Few During a review of Resident 57's MDS, dated [DATE], the MDS indicated Resident 57's cognitive skill for daily decision-making was moderately impaired and with moderate assistance for ADLs- bed mobility, dressing, toilet use, and personal hygiene). MDS also indicated Resident 57 was at risk for developing pressure ulcers /injuries and receiving treatment such as pressure reducing device for bed. During a review of Resident 57's Order Summary Report, dated 11/11/2023. The Order Summary Report indicated Resident 57 had an order for low air loss mattress for wound prevention and comfort. During a review of Resident 57's chart, Resident 57 weighed 111.6 lbs. on 10/25/2023. During a concurrent observation and interview on 11/10/2023 at 12:50 p.m., Resident 57 was observed laying in a LAL mattress bed at a setting of 240 lbs. Resident 57 stated being uncomfortable. During an interview with the Director of Staff and Development (DSD), on 11/10/2023 at 12:52 p.m., the DSD stated that LAL mattress should be set by weight and comfort of the resident. During an interview with the Treatment Nurse 1 (TN 1), on 11/11/2023 at 12:55 p.m., the TN1 stated that LAL mattress setting should be based on resident's weight and comfort. A review of facility's P&P, titled, Support Surface Guidelines, reviewed on 4/2023, P&P indicated redistributing support surfaces are to promote comfort for all bed- or chairbound residents, prevent skin breakdown, promote circulation and provide pressure relief or reduction. Based on observation, interview and record review, the facility failed to ensure the appropriate setting of the low air loss mattress (LAL-a mattress designed to prevent and treat pressure wounds) was properly set up for two of two sampled residents, (Residents 38 and 57) according to the residents' needs and professional standard of care. This deficient practice placed Residents 38 and 57 at risk of poor wound healing of the current pressure ulcer (skin and soft tissue injuries that form as a result of constant or prolonged pressure exerted on the skin) and had a potential to develop new pressure sores/wounds. Findings: A. A review of Resident 38's admission record indicated Resident 38 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including severe sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs) metabolic encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood) and primary osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down). A review of Resident 38's Minimum Data Set (MDS - a comprehensive assessment and care screening 055711 Page 26 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0686 Level of Harm - Minimal harm or potential for actual harm tool), dated 10/27/2023, indicated Resident 38's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were moderately impaired and required maximal assistance to dependent from staff for activities of daily livings (ADLs- roll left and right, sit to lying, lying to sitting and car transfer). The same MDS further indicated that Resident 38 has a pressure ulcers/injury and is using a pressure reducing device for bed. Residents Affected - Few A review of Resident 38's care plan for at risk for skin breakdown, initiated on 10/23/2023 indicated a goal of, resident will be free of skin breakdown, with interventions that included, pressure relieiving device while in bed and in wheelchair A review of Resident 38's Physician Order Summary Report, dated 11/2/2022 indicated, an order for LAL related to pressure injury every day per shift. A review of Resident 38's Weights and Vitals Summary, dated 11/8/2023 indicated Resident 38's weight was 188.4 pounds (lbs.). During an observation of Resident 38 on 11/10/2023 at 11:28 a.m., observed Resident 38 lying on a bed with a LAL mattress with the machine turned off. During an observation of Resident 38 on 11/10/2023 at 12:45 p.m., observed Resident 38 lying on a bed in a LAL mattress with the setting at 120 lbs. During a concurrent interview with Registered Nurse 1 (RN 1) and observation with Resident 38 on 11/10/2023 at 4:40 p.m., RN 1 stated, the LAL mattress for Resident 38 was set to 120 lbs. RN 1 stated, Resident 38 does not weight 120 lbs and the setting for the LAL mattress was incorrect. A review of the facility's policy and procedures (P & P) titled, Support Surface Guidelines, revised on April 2023 indicated, The purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown. 055711 Page 27 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 implement their policy and procedure (P&P) titled, Personal Alarms, for one of 22 sampled residents, (Resident 28) who are at risk for falls. This deficient practice placed Resident 28 at risk for fall and sustain an accidental injury. Findings: A review of Resident 28's admission Record indicated Resident 28 was admitted to the facility on [DATE], with diagnoses including intervertebral disc degeneration (when the spinal disks wear down), unspecified dementia (loss of cognitive functioning-thinking, remembering, and reasoning) and major depressive disorder (a mood disorder that causes persistent feeling of sadness and loss of interest). A review of Resident 28's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 10/17/2023, indicated Resident 28's cognitive skills for daily decision-making were severely impaired and required maximal assistance from staff for activities of daily living (ADLs- oral hygiene, lower body dressing, sit to lying and to stand and walking 10 feet). A review of Resident 28's Physician's Order Summary Report, dated 10/13/2023 indicated, Monitor tab alarm placement and functionality every shift. A review of Resident 28's care plan for at risk for falls related to weakness, initiated on 10/13/2023, had a goal of, Resident will have no incident of falls/injury every shift, with interventions that included, maintain a safe and hazard free environment . During an observation with Resident 28 on 11/10/2023 at 4:07 p.m., observed Resident 28 lying on a bed with the tab (personal) alarm disconnected from the electric cord and from the resident, and the alarm was on the floor. During a concurrent observation and interview with Certified Nursing Assistant 1 (CNA 1), on 11/10/2023 at 4:09 p.m., CNA 1 stated and confirmed, the tab (personal) alarm was disconnected from the electric power cord and from Resident 28's clothing, therefore it won't work. During an interview with Licensed Vocational Nurse (LVN 2), on 11/10/2023 at 4:12 p.m., LVN 2 stated, the tab (personal) should be connected to the electric power cord and to the resident for it to alarm when resident tries to get out of bed on their own. LVN 2 stated, if the device used to prevent falls is not working properly, then it puts Resident 28 at risk for falls. A review of the facility's P&P titled, Personal Alarms, revised May 2023 indicated, Nursing staff will check placement of the device alarm, function and continue need during the shift. 055711 Page 28 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to ensure resident received appropriate treatment and services to prevent urinary tract infections (UTI-an infection in any part of your urinary system your kidneys, ureters, bladder and urethra) for one of three sampled residents (Resident 177) by failing to ensure Resident 177's indwelling urinary (foley) catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) was placed below the level of the bladder at all times. This deficient practice had the potential to result in urinary tract infections for Resident 177. This deficient practice had the potential for Resident 177 to be at risk for complications related to indwelling catheters such as UTI. Findings: A review of Resident 177's admission Record indicated resident was admitted to the facility on [DATE] with diagnoses including type II diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), anemia (a condition which the blood does not have enough health red blood cells), and retention of urine (a condition in which you are unable to empty all the urine from your bladder). A review of Resident 177's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 11/10/2023, indicated Resident 177's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were intact and required moderate assistance from staff for activities of daily living (ADLs- toileting, shower/bathing, lower body dressing). A review of Resident 177's Care Plan for potential reoccurrence of bladder infection related to history of UTI and use of catheter, dated initiated on 11/6/2023, with a goal of will be able to assess signs and symptoms of bladder infection and prevent reoccurrence, had an intervention to, observe for signs of UTI . and turn and reposition at regular intervals to prevent urine stagnation. During the facility tour on 11/10/2023 at 11:17 a.m., observed Resident 177 lying in the bed with a urinary catheter placed higher than level of her bladder and the urine in the tubing was observed flowing back to her blader, not in the urinary drainage bag. During a concurrent observation and interview with Director of Staff and Development (DSD), on 11/10/2023 at 11:26 a.m., DSD observed and confirmed, Resident 177's urinary catheter drainage bag was placed higher than her [Resident 177] bladder, with the urine backflowing in the bladder. DSD stated the urinary drainage bag was placed incorrectly and should be placed below her [Resident 177] bladder to prevent backflowing of the urine. DSD further stated, this placed Resident 177's at risk of UTI. A review of the facility's policy and procedures (P&P) titled, Catheter Care, Urinary, revised on September 2023 indicated, the purpose of this procedure is to prevent catheter-associated urinary tract infections . the urinary drainage bag must be held or positioned lower than the bladder at all 055711 Page 29 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0690 times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055711 Page 30 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. A review of Resident 36's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including hemiplegia and hemiparesis (loss of the ability to move in one side of the body) following cerebral infarction (also known as a stroke- refers to damage to tissues in the brain due to a loss of oxygen to the area) affecting right dominant side, end stage renal disease (ESRD-a medical condition in which a person's kidney stops functioning on a permanent basis), and congestive heart failure (a condition in which the heart does not pump blood as well as it should). Residents Affected - Few A review of the MDS dated [DATE], indicated Resident 36's cognitive skills for daily decision-making were moderately impaired and required moderate assistance from staff for ADLs (activities of daily living- such as oral hygiene, toileting, shower/bathing, lower body dressing). A review of Resident's 36's Physician Order Summary Report, dated 11/8/2023 indicated an order: fluid restriction 1500-millimeter (ml) per day, nursing to provide 540 ml/day; 200 ml on morning (AM) shift, 200 ml on evening (PM) shift, 140 ml on night (NOC) shift; dietary to provide 960ml-breakfast 480ml, lunch 240ml, dinner 240ml for chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure). A review of Resident 36's care plan for nutritional problem related to .CKD, initiated on 1/17/2022, indicated a goal of resident will maintain adequate nutritional status as evidenced by having no weight significant weight changes, with interventions that included, fluid restriction 1500 ml/day . A review of the Medication Administration Record (MAR) for the month of November 2023 indicated physician's order of fluid restrictions: 1500 ml/day nursing to provide 540 ml/day; AM shift - 200 ml - PM shift - 200 ml; NOC shift - 140 ml; (dietary to provide 960 ml/day). The MAR for November 2023 indicated the following fluid intakes: I. 11/1/2023 - on AM shift, nurses provided 920 ml of fluid; PM shift: 440 ml, NOC shift: 140 ml (total of 1500 ml) II. 11/2/2023 - AM shift - 920 ml; PM shift - 440 ml; NOC shift - 140 (total of 1500 ml) III. 11/3/2023 - AM shift - 920 ml; PM shift - 440 ml; NOC shift - 70 (total of 1430 ml) IV. 11/4/2023 - AM shift - 920 ml; PM shift - 440 ml; NOC shift - 60 (total of 1420 ml) V. 055711 Page 31 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0692 11/5/2023 - AM shift - 900 ml; PM shift - 360 ml; NOC shift - 60 (total of 1320 ml) Level of Harm - Minimal harm or potential for actual harm VI. 11/6/2023 - AM shift - 900 ml; PM shift - 400 ml; NOC shift - 140 (total of 1440 ml) Residents Affected - Few VII. 11/7/2023 - AM shift - 400 ml; PM shift - 440 ml; NOC shift - 140 (total of 980 ml) VIII. 11/9/2023 - AM shift - 1160 ml; PM shift - 440 ml; NOC shift - 60 (total of 1660 ml) IX. 11/10/2023 - AM shift - 1160 ml; PM shift - 440 ml; NOC shift - 120 (total of 1720 ml) During a concurrent interview with Director of Nursing (DON) and record review of Resident 36's medical record on 11/12/2023 at 4:07 p.m., the DON stated and confirmed, Resident 36's fluid restrictions were not followed by the nursing staff. The DON stated the resident's target weight was not being met because of the fluid overload, which placed Resident 38 at risk of over hydration. A review of the facility's P&P titled, Dialysis care, revised May 2023 indicated, monitor intake and output as ordered. Observe fluid restrictions as ordered by the physician. A review of the facility's P&P titled, Intake and Output Policy, revised May 2023 indicated, to provide an accurate record of identified resident's intake and output (I&O) . The license nurse will total the intake by adding the intake reported from Certified Nursing Assistants (CNAs) and the fluid gave with med pass . The license nurse will record the total intake and output on the MAR at the end of each shift. Based on observation, interview, and record review, the facility failed to ensure that two of 15 sampled residents (Residents 11 and 36) were accurately assessed and monitored by failing to: 1. Identify and assess prevent unplanned significant weight loss of 11.4 pounds (lbs) (6.8 percent) in 9 days for Resident 11. 2. Ensure Resident 36 who was on a fluid restriction, received the daily fluids per physician's order and resident's care plan. These deficient practices resulted in Resident 11 having unplanned significant weight loss of 11.4 pounds in 10 days and placed her at a risk for malnutrition; it also had the potential to cause either fluid overload or dehydration for Resident 36. Findings: A. A review of Resident 1's admission Record indicated Resident 11 was admitted to the facility on [DATE] with diagnoses including hypothyroidism (the thyroid gland [butterfly-shaped gland in the 055711 Page 32 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0692 Level of Harm - Minimal harm or potential for actual harm front of the neck] does not produce adequate thyroid hormones to meet the body's needs), overactive bladder (OAB-causes a frequent and sudden urge to urinate that may be difficult to control), and gastro-esophageal reflux disease (GERD-occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach [esophagus]) with esophagitis (inflammation or irritation of the esophagus). Residents Affected - Few A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 10/27/2023, indicated Resident 11 was cognitively (relating to mental ability to make decisions of daily living) intact and required supervision assistance for eating, oral hygiene, personal hygiene. Resident 11 required partial/maximum assistance for upper body dressing. The MDS further indicated that Resident 11 required substantial/maximum assistance for putting on/taking off footwear, rolling left and right, sitting to lying, and sitting to standing. During a concurrent interview and record review of the weight log for Resident 11with Director of Nursing (DON) on 11/12/23 08:20 a.m., the DON confirmed that Resident 11 had a weight loss of 11.4 lbs. between 10/25/2023, weighted 167.8 lbs. and 11/3/23, weighted 156.4 lbs. The DON stated the weight loss was considered significant, adding that the facility protocol when there is significant weight loss is to notify the physician with SBAR (Situation, Background, Assessment, Recommendation- an easy to use, structured form of communication that enables healthcare professionals communicate quickly, efficiently, and effectively), to place the resident on monitoring (for weight and oral intake). The DON also stated the assessment and reviews from Registered Dietician (RD) and Interdisciplinary team meeting (IDT-a group of health care professionals with various areas of expertise who work together toward the goals of their clients)-need be completed as soon the significant weight loss is determined. The DON stated the potential of not addressing the loss would result in the resident's nutritional needs not being met. During an interview with the RD on 11/12/23 at 4:30 p.m., the RD stated she saw Resident 11 on 11/10/2023. The RD also stated that Resident 11 had a significant weight loss that should have been flagged and addressed as soon as it was identified. The RD further stated the potential for the weight loss not being addressed would place Resident 11 at a risk for malnutrition. A review of the policy and procedure titled Weight Assessment and Intervention, revised May 2023, indicated, the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. It further indicated weight assessment: 1. The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks. 2. Weights will be recorded in each unit's Weight Record chart or notebook and in the individual's medical record. 3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietitian in writing. Verbal notification must be confirmed in writing. 4. The Dietitian will review the weekly and monthly Weight Record and follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. 055711 Page 33 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0692 5. The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss = (usual weight- actual weight)/ (usual weight) x 100]: Level of Harm - Minimal harm or potential for actual harm a. 1 month - 5% weight loss is significant; greater than 5% is severe. Residents Affected - Few b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. c. 6 months - 10% weight loss is significant; greater than 10% is severe. 6. If the weight change is desirable, this will be documented and no change in the care plan will be necessary. 055711 Page 34 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0697 Provide safe, appropriate pain management for a resident who requires such services. 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 effectively manage pain for one of 15 sampled residents (Resident 64) by not following physician's medication order. Residents Affected - Few This deficient practice resulted in Resident 64 experienced unnecessary pain. Findings: A review of Resident 64's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including displaced fracture (break in bone) in left tibia (also known as the shinbone or shank bone in the leg below the knee), and fracture of left lower leg, depression (a mood disorder that causes persistent feeling of sadness and loss of interest), and sciatica (pain, weakness, numbness, or tingling in the leg). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 10/30/2023, indicated Resident 64's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were intact. Resident 64 required supervision to moderate assistance from staff for activities of daily living (ADLs- daily activities related to personal care including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). A review of Resident 64's Physician Order Summary Report dated 9/30/2023 indicated, oxycodone (medication that can treat moderate to severe pain) 5 milligram (mg) every 4 hours as needed for mild pain. A review of Resident 64's Care Plan for alteration in comfort, pain, initiated on 10/27/2023, indicated a goal of pain is decreased or controlled as evidenced by decreased # of requests for pain medications (meds) and/or verbalization that pain is tolerable with interventions that includes, to administer meds as ordered, monitor for effectiveness, notify medical doctor (MD) if ineffective. A review of Resident 64's Medication Administration Record (MAR) for the month of October indicated: oxycodone 5mg - give 1 tablet every 4 hours as needed for mild pain, was administered on: i. 10/1/2023 at 12:36 p.m. - Resident 64's pain level of eight out of 10 (8/10 - numerical pain assessment where zero is no pain and 10 is most severe pain). ii. 10/1/2023 at 5:55 p.m. - pain level of 8/10 iii. 10/1/2023 at 10:41 p.m. - pain level of 8/10 iv. 055711 Page 35 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0697 10/2/2023 at 6:05 a.m. - pain level of 7/10 Level of Harm - Minimal harm or potential for actual harm v. 10/3/2023 at 12:34 p.m. - pain level of 7/10 Residents Affected - Few vi. 10/4/2023 at 4:04 a.m. - pain level of 7/10 vii. 10/6/2023 at 5:26 a.m. - pain level of 0/10 viii. 10/7/2023 at 4:58 a.m. - pain level of 7/10 During an interview with Resident 64 on 11/11/2023 at 12:24 p.m., Resident 64 stated she was experiencing severe pain and would request pain medication per physician's order. Resident 64 stated, her pain was not being managed properly as she had experienced pain constantly. Resident 64 stated, she her pain level was 8/10 throughout the day. During an interview with Director of Nursing (DON) on 11/12/2023 at 4:37 p.m., the DON stated, pain level of 1-3/10 is mild pain, and 6-10/10 is severe pain. The DON stated, for resident experiencing severe pain, staffs should administer pain medications for severe pain following the physician's order. The DON stated, Resident 64 was given pain medications for mild pain instead of severe pain as Resident 64 reported her pain level was 8/10. The DON stated Resident 64's pain was not managed properly. A review of the facility's policy and procedure (P&P) titled, Pain Management, revised March 2023 indicated, The nursing staff will identify the characteristics of pain such as location, intensity, frequency, pattern, and severity. A review of the facility's P&P titled, Pain Assessment and Management, revised March 2022, The purpose of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain . pain management interventions shall reflect the sources, type and severity of pain. 055711 Page 36 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 ensure one of the 22 sampled residents (Resident 9) psychoactive medication clonazepam (klonopin- a long-acting benzodiazepine with intermediate onset commonly used to treat panic disorders, severe anxiety, and seizures [is a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations or states of awareness]), by failing to ensure: Residents Affected - Few 1. Klonopin was necessary to treat a specific diagnosis and the condition documented. 2. The Pharmacist's recommendations were followed. These deficient practice had the potential to place Resident 9 at risk of receiving unnecessary medication. Findings: A review of Resident 9's admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including essential hypertension (high blood pressure that is multi-factorial and doesn't have one distinct cause with above-normal blood pressure is typically anything over 120/80), malignant neoplasm of prostate (Prostate cancer is cancer that occurs in the prostate. The prostate is a small walnut-shaped gland in males that produces the seminal fluid), and radiculopathy, lumber region (an inflammation of a nerve root in the lower back, which causes symptoms of pain or irritation in the back and down the legs). A review of Resident 9's history and physical (the most formal and complete assessment of the patient and the problem. Physicians documentation are produce through the interview with the patient, the physical exam, and the summary of the testing either obtained or pending) dated 10/16.2023 indicated, Resident 9 had the capacity to understand and make decisions. During an interview with Resident 9 on 11/10/2023 at 11:46 a.m., Resident 9 stated that he was unable to sleep well at night because his roommate coughs throughout the night. Resident 9 further stated that he had made the staff and the Director of Nursing (DON) aware about these issues and was offered a room change. A review of the physician's order dated 11/10/2023 indicated clonazepam tablet 0.5 mg tablet by mouth at bedtime for anxiety manifested by inability to sleep. During a concurrent interview and record review with the DON, on 11/12/23 at 11:44 a.m., the DON stated that whenever a resident is having a hard time sleeping, a room change is offered if it is because of environmental factors. If disturbance not due to environmental factors, then routines such as set times for sleeping then eventually sleep medications are added. The DON admitted that Resident 9 did not have a diagnosis for anxiety. The DON further stated that having a diagnosis for ordered medications especially psychoactive medications, staff have to ensure that the resident was receiving treatments for a condition that had been diagnosed. A review of the facility's policy and procedures titled Psychotropic Medication Use Policy, revised January 2023 indicated, It is the policy of this facility that: 055711 Page 37 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0757 Level of Harm - Minimal harm or potential for actual harm All residents receiving psychotropic medication(s) prescribed for control of a specific behavior or manifestation of a disordered thought process shall be monitored for effectiveness of the medication and for adverse drug reactions. It further indicated the resident or designated responsible party has the right to make decisions with regard to his/her medical condition, to receive information related to the need for and the risks related to the use of psychotherapeutic drugs. Residents Affected - Few 055711 Page 38 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

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 ensure that one of five sampled residents (Resident 7's) psychotropic (relating to or denoting drugs that affect a person's mental state) medication regimen was managed and monitored to promote or maintain the highest practicable mental, physical, and psychosocial well-being by failing to ensure: 1. The implementation of monitoring episodes of anxiety for Resident 7's alprazolam (anti-anxiety medication) use. 2. The implementation of monitoring for any potential side effect and/or adverse reaction for Resident 7's alprazolam use. 3. The implementation of monitoring episodes of depression for Resident 7's citalopram hydrobromide (anti-depressant medication) use. 4. The implementation of monitoring for any potential side effect and/or adverse reaction for Resident 7's citalopram hydrobromide use. 5. Ensure Resident 7's citalopram hydrobromide use had indicated manifestation of behavior specific for the diagnosis. These deficient practices had the potential to place Resident 7 at risk of receiving unnecessary medications and/or overuse of medication, and at risk for adverse consequences while taking psychotropic medications. Findings: A review of Resident 7's admission Record indicated the facility originally admitted Resident 7 on 9/3/2023 and readmitted on [DATE] with diagnoses including fracture of bilateral humerus (a break, crack or crush injury of the bone in both arms), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body). A review of Resident 7's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 9/18/2023, indicated Resident 7's cognitive skill for daily decision-making was intact and required with one-person physical assistance for activities of daily livings (ADLs- bed mobility, dressing, toilet use, and personal hygiene). A review of Resident 7's Order Summary Report indicated Resident 7 had the following active orders: - Citalopram Hydrobromide 20 milligram (mg) by mouth once a day for depression, ordered on 9/14/2023 -Alprazolam 1 mg by mouth tow times a day for anxiety, ordered on 11/10/2023 During a concurrent record review and interview with the Director of Nursing (DON) on 11/12/2023 at 055711 Page 39 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0758 7:32 p.m., the DON verified Resident 7's missing orders for the following: Level of Harm - Minimal harm or potential for actual harm 1. Monitoring episodes of anxiety for Resident 7's alprazolam use. 2. Monitoring for any potential side effect and/or adverse reaction for Resident 7's alprazolam use. Residents Affected - Few 3. Monitoring episodes of depression for Resident 7's citalopram hydrobromide use. 4. Monitoring for any potential side effect and/or adverse reaction for Resident 7's citalopram hydrobromide use. 5. Manifestation of behavior specific for the diagnosis for Resident 7's citalopram hydrobromide use. The DON stated importance of monitoring each behavior and potential side effect/ adverse reaction of all psychotropic medications and making sure that for every psychotropic medication will have manifestations of behavior. A review of the facility's policy and procedure (P&P), Psychotropic Medication Use Policy, revised 9/2023, indicated that for each routine and PRN psychotropic medication: -The medication, dose and frequency will be indicated in the clinical record and consent. -A specific condition being treated will be identified in the physician's order - Behavior manifestations will be identified in the care plan. - The number of behavior episodes will be collected on the medication sheet. - A summary of behavior episodes and presence of side effects will be complied for the prescriber on a monthly basis. - Evidence of behavior assessment and attempts at gradual dose reduction will be documented in the medical record. - Excessive use of PRN antipsychotics will be assessed and prescriber notified. -Recommendations for changes in psychotropic medication regimen will be directed to the prescriber. The P&P also indicated that facility will provide a method of assessing those residents receiving psychotropic medication to ensure: - Alternative behavior management have been attempted prior to the use of psychotropic medications. -Behavior management are a continuing part of the resident's plan of care. -Early identification and reporting of drug side effects. 055711 Page 40 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0758 Level of Harm - Minimal harm or potential for actual harm -Summaries of resident behavior manifestation, frequency, response to behavioral programs and medications as well as recommendations for changes in medication are provided to the physician. -Psychotropic medications are used in the lowest possible does and are discontinued when no longer required. Residents Affected - Few 055711 Page 41 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of Resident 6's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including CKD, acute respiratory failure, and type II DM. A review of Resident 6's MDS, dated [DATE], indicated Resident 6's cognitive skills for daily decision-making were intact and required maximum of assistance to dependence from staff for ADLs. A review of Resident 6's Physician Order Summary Report, dated 10/29/2023 indicated, DuoNeb 3-millimeter (ml) inhale (breathe in) every four hours as needed for shortness of breath or wheezing (high pitched sound when inhaling). During a concurrent observation and interview with Licensed Vocational Nurse 6 (LVN 6) on 11/12/2023 at 11:46 a.m., Resident 6's undated opened foil pack of DuoNeb was observed in Medication Cart 2. LVN 6 stated that foil pack should have a date when it was opened. A review of the facility's P&P, titled, Administering Medications, revised on 4/2023, the P&P indicated that when opening a container, the date opened is recorded. A review of DuoNeb's manufacturer's policy, undated, indicated that once open/removed from the foil pouch, should be used within a week. 4a. A review of Resident 175's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including neoplasm (a new and abnormal growth of tissues) of digestive organs (includes mouth, throat, esophagus, stomach, small intestine, large intestine, rectum and anus), and glaucoma (eye condition that can cause blindness). A review of Resident 175's Physician Order Summary Report, dated 10/20/2023 indicated, travoprost hydrochloride (eye drop used to treat increased pressure in the eye) 0.004 percent (%) to instill one drop in both eyes at bedtime for glaucoma. During a concurrent observation and interview with LVN 6 on 11/12/2023 at 11:57 a.m., Resident 175's travoprost eye solution container with a sticker indicated refrigerate was observed inside Medication Cart 2. LVN 6 stated that medication should be inside the refrigerator per pharmacy policy. A review of the facility's P&P, titled, Storage of Medication, revised on 1/2023, the P&P indicated that the facility stores all drugs and biologicals in a safe, secure, and orderly manner. The P&P also indicated that medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location. 4b. A review of Resident 232's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including urinary tract infection (UTI-infection in the urinary system [kidneys, bladder, or urethra]), and glaucoma. A review of the Resident 232's MDS, dated [DATE], indicated Resident 232's cognitive skills for daily decision-making were intact and the resident was dependent on staff for ADLs. 055711 Page 42 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 232's Physician Order Summary Report, dated 11/9/2023 indicated, latanoprost 0.005 % (eye drop used to treat increased pressure in the eye) to instill one drop in both eyes at bedtime for glaucoma. During a concurrent observation and interview with LVN 6 on 11/12/2023 at 11:57 a.m., Resident 232's latanoprost eye solution container with a sticker indicated refrigerate was observed inside Medication Cart 2. LVN 6 stated that medication should be stored inside the refrigerator per pharmacy policy. A review of the facility's P&P, titled, Storage of Medication, revised on 1/2023, the P&P indicated that the facility stores all drugs and biologicals in a safe, secure, and orderly manner. The P&P also indicated that medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location. Based on observation, interview and record review, the facility failed to ensure safe provision of pharmaceutical services by failing to: 1. Ensure Resident 6's self-administered medication was properly stored. 2. Ensure one of two medication storage refrigerator (refrigerator 1's) temperatures were within the acceptable range. 3. Ensure proper labeling of an opened foil pack of DuoNeb (medication to treat symptoms associated with lung disease) for Resident 6. 4. Ensure ophthalmic (eye) medications were refrigerated per pharmacy for Resident 175 and 232. These deficient practices had the potential to compromise the safety and effectiveness of medications, resulting in possible medication errors. Findings: 1. A review of Resident 6's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure), acute respiratory failure (a serious condition that makes it difficult to breathe on your own), and type II diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 11/2/2023, indicated Resident 6's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were intact, Resident 6 required maximum assistance to dependence from staff for activities of daily living (ADLs- oral hygiene, toileting, shower/bathing, personal hygiene). A review of Resident 6's Physician Order Summary Report, dated 11/10/2023 indicated, Fluticasone propionate suspension (a nasal spray used to relieve symptoms of nonallergic rhinitis [reactions that causes nasal congestion] such as sneezing and runny or stuffy nose) 50 microgram/actuation (mcg/act) - 1 spray in each nostril as needed for allergic rhinitis unsupervised self-administration, okay to have at bedside, patient may self-administer. 055711 Page 43 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During the facility tour on 11/10/2023 at 4:25 p.m., Resident 6 was not in his room. However. fluticasone nasal spray was observed stored on top of Resident 6's bed, accessible to others. During an interview with Registered Nurse 1 (RN 1) on 11/10/2023 at 4:35 p.m. in Resident 6's room, RN 1 stated Resident 6's fluticasone nasal spray medication was on top Resident 6's bed and it(medication) should be stored securely and not accessible by others. RN 1 further stated, if the medication at bedside is stored unsecured, this puts other residents and visitors at risk of taking the medications unattended without knowing what it is for. A review of the facility's policy and procedure (P&P) titled, Self-Administration of Medications, revised February 2023 indicated, Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. 2. During a concurrent interview and observation of Medication room [ROOM NUMBER] with RN 2 on 11/12/2023 at 10:18 a.m., there was one refrigerator inside the medication room, RN 2 stated the refrigerator contained IV (intravenous) medications for the residents in the facility. A review of the IV refrigerator temperature log for the month of October indicated the following: i. 10/12/2023 - temperature of 32 degrees Fahrenheit (F) ii. 10/12/2023 - 32 degrees F iii. 10/13/2023 - 32 degrees F iv. 10/14/2023 - 32 degrees F v. 10/15/2023 - 32 degrees F vi. 10/16/2023 - 34 degrees F vii. 10/17/2023 - 34 degrees F During an interview with RN 2 on 11/12/2023 at 10:30 a.m., RN 2 stated, the temperatures of the refrigerator are checked in the morning shift and the night shift, and the acceptable temperature range 055711 Page 44 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was between 36 degrees F - 46 degrees F. RN 2 stated and confirmed, the IV refrigerator temperature for the month of October was out of the acceptable range. RN 2 stated, this might affect the medications being stored in the refrigerator. During an interview with Director of Nursing (DON) on 11/12/2023 at 4:51 p.m., the DON stated, when the medications refrigerator temperature is out of within the range, staffs should contact the maintenance department to assess the equipment. The DON stated, there was no documentation that the staffs had contacted the maintenance regarding the IV refrigerator when the temperatures were out of range. A review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, updated on August 2023 indicated, medication requiring refrigeration or temperatures between 36 degrees F and 46 degrees F are kept in a refrigerator with a thermometer to allow temperature monitoring. 055711 Page 45 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to maintain accurate medical record in accordance with accepted professional standards and practices for one of 22 sampled residents (Resident 33) by failing to ensure Resident 33's change of condition documentation on 10/25/2023 was documented via late entry. Resident 33 was transferred to an acute care hospital (GACH) on 10/24/2023. This deficient practice had the potential to negatively impact the delivery of service given to Resident 33. Findings: A review of Resident 33's admission Record indicated the facility originally admitted Resident 33 on 8/31/2023 and readmitted on [DATE] with diagnoses including sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), urinary tract infection (UTI-a bacterial infection of the bladder and associated structures). admission Record also indicated Resident 33 was transferred to GACH on 10/24/2023. A review of Resident 33's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 9/30/2023, indicated Resident 33's cognitive skill for daily decision-making was severely impaired and required limited to extensive assistance from staff for activities of daily livings (ADLs- bed mobility, dressing, toilet use, and personal hygiene). A review of Resident 33's order summary report dated 10/24/2023, indicated an order to transfer Resident 33 to GACH for cough, abdominal pain and leukocytosis (elevated white blood cells [body cell that contains antibodies for infection]). A review of Resident 33's SBAR (situation, background, appearance and review/notify- structured tool for healthcare provider that provides communication between members. Also, being used as documentation for any changes of condition) dated 10/24/2023, indicated Resident 33 had a change in condition due to leukocytosis and was transferred to GACH. A review of Resident 33's SBAR dated 10/25/2023, indicated the resident had a change in condition due to weight loss. During an interview with Licensed Vocational Nurse 5 (LVN 5) on 11/12/2023 at 3:52 p.m., LVN 5 stated that she (LVN 5) was not supposed to complete the SBAR for weight loss if she had known at that time Resident 33 was transferred to GACH on 11/24/2023. A review of the facility's policy and procedure (P&P), titled, Charting Errors/Omissions/Late Entry, revised 1/2023, P&P indicated that accurate medical records shall be maintained by the facility and that if there is a necessity to change or add information in the resident's medical record, it shall be completed by means of addendum and late entries in the medical record shall be dated at the time of entry and noted as a late entry. A review of the facility's P&P, titled, Charting and Documentation, revised on 4/2023, P&P indicated all services provided to the resident or any changes in the resident's medical or mental 055711 Page 46 of 47 055711 11/13/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0842 condition, shall be documented in the resident's medical record. Level of Harm - Minimal harm or potential for actual harm A review of the facility's P&P, titled, Change in a Resident's Condition or Status, revised 9/2023, indicated that facility will promptly notify the resident's physician of the changes in resident's medical/mental condition and/or status. Residents Affected - Few 055711 Page 47 of 47