Health inspection·November 27, 2023

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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** Based on observation and interview, facility failed to ensure removal and discarding of discontinued medications for four of four sampled discharged residents (Resident 8, 9, 10 and 14) from the medication storage room per facility's policy. This deficient practice resulted in unsafe storage of the medication, and possibly Residents 8, 9, 10 and 14 inabilities to get the prescribed medications paid by residents ' insurance. Findings: 1. A review of Resident 8 ' s admission Record indicated Resident 8 was admitted to the facility on [DATE], with diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body), dysphagia (difficulty swallowing food or liquid) and dysarthria (difficulty in speaking /slurred speech). Resident 8 was discharged on 3/23/2023. A review of Resident 8's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 2/27/2023, indicated Resident 8 has moderately impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and requiring limited assistance from staff for activities of daily living (ADL-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). During a concurrent observation in the medication room and interview with the Director of Nursing (DON) on 11/27/2023 at 2:20 p.m., observed Resident 8 ' s medication bubble packs (medication packaging dispensing system) inside the medication cabinet for the following medication: · Eliquis (blood thinner medication) 5 milligram (mg) tablet by mouth twice daily · tamsulosin hydrochloride (hcl) (medication that relaxes bladder and prostate [accessory gland of the male reproductive system])0.4 mg capsule by mouth at bedtime, DON verified and stated that Resident 8 had been discharged . DON stated that it should have been given to the resident or discarded by the night shift nurse. 2. A review of Resident 9 ' s admission Record indicated Resident 9 was originally admitted to the facility on [DATE] and was re-admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe), Page 1 of 3 055711 055711 11/27/2023 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0761 Level of Harm - Minimal harm or potential for actual harm hypoxia (absence of enough oxygen in the tissue to sustain bodily functions) and abnormalities of gait and mobility. Resident 9 was discharged on 2/21/2023. A review of Resident 9's MDS, dated [DATE], indicated Resident 9 has intact cognition for daily decision-making and requiring limited to extensive assistance from staff for ADLs. Residents Affected - Few During a concurrent observation in the medication room and interview with the DON on 11/27/2023 at 2:21 p.m., observed Resident 9 ' s medication bubble packs inside the medication cabinet for the following medications: · Rosuvastatin calcium (medication that treat high cholesterol level in blood) 10 mg tablet by mouth at bedtime · Hydralazine (medication for high blood pressure) 50 mg tablet by mouth three times a day. DON verified and stated that Resident 9 had been discharged . DON stated that it should have been given to the resident or discarded by the night shift nurse. 3. A review of Resident 10 ' s admission Record indicated Resident 10 was admitted to the facility on [DATE], with diagnoses including 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), congestive heart failure (CHF-a chronic condition in which the heart does not pump blood as well as it should) and diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]). Resident 10 was discharge on [DATE]. A review of Resident 10's MDS, dated [DATE], indicated Resident 10 has intact cognition for daily decision-making and requiring limited to extensive assistance from staff for ADLs. During a concurrent observation in the medication room and interview with the DON on 11/27/2023 at 2:22 p.m., observed Resident 10 ' s medication bubble packs inside the medication cabinet for the following medications: · Warfarin sodium (blood thinner) 2.5 mg tablet by mouth daily · Metoprolol (medication for high blood pressure) 50 mg tablet by mouth daily · Mycophenolate (medication to prevent organ rejection) 500 mg tablet by mouth two times per day · Prednisone (anti-inflammation medication) 20 mg tablet by mouth two times per day DON verified and stated that Resident 10 had been discharged . DON stated that it should have been given to the resident or discarded by the night shift nurse. 4. A review of Resident 14 ' s admission Record indicated Resident 14 was admitted to the facility on [DATE], with diagnoses including osteoporosis (a condition in which bones become weak and brittle), left artificial hip joint and hyperlipidemia (abnormally high levels of fats in the blood). Resident 14 was discharge on [DATE]. 055711 Page 2 of 3 055711 11/27/2023 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 - Few A review of Resident 14's MDS, dated [DATE], indicated Resident 14 has intact cognition for daily decision-making. During a concurrent observation in the medication room and interview with the DON on 11/27/2023 at 2:23 p.m., observed Resident 14 ' s medication bubble packs inside the medication cabinet for the following medications: · Levothyroxine (medication to produce thyroid gland hormone) 150 microgram (mcg) tablet by mouth daily · Methocarbamol (muscle relaxant medication) 500 mg tablet by mouth three times daily · Ondansetron (medication for nausea) 4 mg tablet by mouth every eight hours as needed · Celexa (anti-depressant medication) 20 mg tablet by mouth daily · Simvastatin (medication that treat high cholesterol level in blood) 20 mg tablet by mouth at bedtime DON verified and stated that Resident 14 had been discharged . DON stated that it should have been given to the resident or discarded by the night shift nurse. A review of the facility ' s policy and procedures (P&P), titled, Storage of Medications, revised on 4/2023, P&P indicated that the facility stores all drugs, and biologicals in a safe, secure and orderly manner. P&P also indicated that discontinued, outdated or deteriorated drugs are returned or destroyed. A review of the facility ' s P&P, titled, Discarding and Destroying Medications, reviewed on 4/2023, P&P indicated that the medications will be disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances. 055711 Page 3 of 3