Health inspection·October 18, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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** Based on observation, interview, and record review, the facility failed to ensure staff provided dignified dining experience while assisting two of 15 sampled residents (Residents 4 and 58) during meals; by ensuring Residents 4 and 58 were fed at eye level to maintain face-to-face contact with the residents. This deficient practice had the potential to result in feelings of decreased self-esteem and self-worth for Resident 4 and Resident 58). b. During a review of Resident 58's admission record indicated the facility admitted the resident on 9/26/2024 with diagnoses that included dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing) and muscle weakness (a lack of strength in the muscles). During a review of Resident 58's Skilled Nursing Facility admission History and Physical (H&P), dated 9/27/2024, indicated Resident 58 was recently hospitalized for acute (of sunset onset) or chronic (on going) functional decline, progressive neurologic (relating to the nervous system or nerves) declined, and had experienced a cognitive (the mental ability to make decisions) decline for the past 18 to 20 months. The H&P also indicated Resident 58 could make needs known but could not make medical decisions due to cognitive deficits and dementia (a progressive state of decline in mental abilities). During a review of Resident 58's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/30/2024, indicated the resident was able to understand others and was able to make himself understood. The MDS also indicated the resident had severely impaired cognition (ability to think, read, learn, remember, reason, express thoughts and make decisions). Resident 58 was dependent upon staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 58 was diagnosed with dementia was receiving antipsychotic and antianxiety medication. During a review of Resident 58's Order Summary Report, dated 10/18/2024, indicated a physician's order for a certified nursing assistant (CNA) to assist in feeding Resident 58. During a review of Resident 58's nutritional problem care plan developed on 10/2/2024, indicated the Resident 58's nutritional problem was due to the resident's chewing difficulties. The care plan interventions included for staff to provide and serve diet as ordered and for staff to monitor and record intake of every meal for Resident 58. During an observation on 10/15/2024 at 12:39 PM, Certified Nursing Assistant 1 (CNA 1) was observed Page 1 of 27 055711 055711 10/18/2024 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0550 on the right side of Resident 58's bed standing over feeding Resident 58. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 10/15/2024 at 12:45 PM in Resident 58's room, CNA 1 was observed standing over Resident 58 while feeding the resident. CNA 1 stated CNA 1 should not stand over Resident 58 while feeding the resident to maintain the resident's dignity. Residents Affected - Some During an interview on 10/18/2024 at 3:45 PM, with the Director of Nursing (DON), the DON stated staff should be sitting and at eye level with the resident when feeding the residents. The DON stated, Staff should feed residents at eye level and not stand over the residents while feeding the residents. The DON further stated, we feed the residents at eye level with the resident when feeding to show dignity for the resident. During a review of the facility's policy and procedures (P&P) titled, Dignity, revised 11/2023, indicated, each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents provided with a dignified dining experience. a. During a review of Resident 4's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure), major depressive disorder (A mental health condition that involves persistent feelings of sadness, hopelessness, and a loss of interest in activities), congestive heart failure (a serious condition that occurs when the heart can't pump enough blood to meet the body's needs) and, neoplasm (cancer) of the prostate (a gland in the male reproductive system). During a review of Resident 4's MDS, dated [DATE], indicated Resident 4's mental cognition was moderately impaired. The MDS indicated Resident 4 required partial moderate assistance for eating and oral hygiene and upper body dressing, was dependent for toileting hygiene, shower/bathing self, and lower body dressing. During a review of Resident 4's care plan titled, The Resident has Limited Physical Mobility Related to Feeding (R/T) and Needs Assistance with Feeding, initiated on 9/23/2024, indicated Resident 4 had limited physical mobility related to feeding and needs assistance with feeding. During a meal observation on 10/15/2024 at 8:31AM, CNA 5 was observed feeding Resident 4 inside the residents' room. CNA 5 was standing to the right side of Resident 4 while feeding the resident. During an interview on 10/15/2024 at 8:37 AM, CNA 5 stated CNA 5 is supposed to beside the patient while assisting the resident with feeding. During an interview on 10/15/2024 at 12:51 PM with Director of Staff Development (DSD), DSD stated, CNAs are supposed to be seated, have eye level contact with the resident when assisting the resident with feeding. During an interview on 10/18/2024 at 4:43 PM with Director of Nursing (DON), DON stated, CNAs should sit on a chair at eye level on the side that is easy for the resident to eat, ensure the resident is not looking up at the staff and is eating at a comfortable pace for the resident dignity. DON further stated assisting a resident with feeding while standing up diminishes the resident's dignity. During a review of the facility's policy and procedures (P&P) titled, Dignity, revised 11/2023, 055711 Page 2 of 27 055711 10/18/2024 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0550 Level of Harm - Minimal harm or potential for actual harm indicated, each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents provided with a dignified dining experience. Residents Affected - Some 055711 Page 3 of 27 055711 10/18/2024 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. 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's interdisciplinary team (IDT-- a group of health care professionals with various areas of expertise who work together toward the goals of their clients) failed to ensure that one of 13 sample residents (Resident 53) did not keep medications at the bedside without a physician's order and/or without being assessed to determine if the resident is capable to self-administer medications. Residents Affected - Few This deficient practice resulted in Resident 53 keeping a white powder like substance inside the medication dispensing cup and self-applying the white powder under the breasts. This deficient also, had the potential for the white powder to be accessed and used by unintended person. Cross Reference F760 Findings: During a review of the admission record indicated Resident 53, was admitted to the facility on [DATE], with diagnoses including acute respiratory failure with hypoxia (a serious medical condition that occurs when the lungs have trouble loading the blood with enough oxygen and body tissues), congestive heart failure (a serious condition that occurs when the heart can't pump enough blood to meet the body's needs.), major depressive disorder (A mental health condition that involves persistent feelings of sadness, hopelessness, and a loss of interest in activities), muscle weakness and dysphagia (medical term for swallowing difficulties). During a review of Resident 53's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 09/21/2024, indicated Resident 5's cognition (The mental ability to make decision of daily living) was intact. The MDS indicated Resident 53 was independent with eating, oral hygiene, and required partial moderate assistance with upper body dressing, was dependent for Toileting hygiene, shower/bathe, lower body dressing, required limited assistance with his activities of daily living. During a concurrent observation and interview on 10/15/2024, at 7:56 AM, Resident 53's bedside drawer was observed with unlabeled medication dispensing cup and a white powder like substance inside the medication dispensing cup. Resident 53 was asked if she knew what the white powder that was inside the unlabeled medication cup. Resident 53 stated, it is antifungal (medication to treat fungal infection/s) powder and that she applies the powder under her breast. During an interview on 10/15/2024, at 7:56 AM., Certified Nursing Assistant 5 (CNA5) stated CNA 5 did not know what was in the medicine cup. CNA5 further stated, it looks like a powder the white powdered substance. During an interview on 10/15/2024 at 8 AM., with the Treatment Nurse 1 (TXN 1), TXN 1 stated TXN 1 did not know what the white powdered substance in the medication dispensing cup on top of Resident 53's bedside drawer was. TXN 1 further stated, the powder in the medication cup is not supposed to be on top of resident's bedside drawer, because it is not labeled and thus unidentifiable. TXN 1 also stated leaving an unlabeled medication cup with an unidentifiable powder in places the Resident at risk of ingesting a white powder that may be unsafe for consumption and if consumed could cause an allergic reaction that could result in anaphylaxis and even death. 055711 Page 4 of 27 055711 10/18/2024 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 10/18/2024 at 4:53 pm with the Director of Nursing (DON), the DON stated, Residents are only allowed for have medications at bedside if they have been assessed to be cognitively intact and have physically demonstrated that they can safely be able to do so and have a physician approval. The DON stated without resident assessment, the medication may be applied/administered incorrectly, placing the resident at risk for skin breakdown, irritation, and or redness. The DON also stated medication at bedside should be secured in a locked container. During a review of the Physician Orders dated 10/18/2024, indicated no order to apply antifungal powder under Resident 53's breasts. During a review of the facility's policy and procedures titled Self-Administration of Medication dated 09/2023 indicated, .the IDT, assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the Resident. Policy further states self-administered medications are stored in a safe and secure place, which is not accessible by other Residents . 055711 Page 5 of 27 055711 10/18/2024 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Based on observation, interview, and record review, the facility failed to provide on-going activities, based on comprehensive assessment and resident's preferences, that meets the interests and to support the physical, mental, and psychosocial well-being of 57 of 57 facility Residents. This deficient practice had the potential to result in lack of feelings of well-being and meaningfulness for the resident. Cross Reference F680 Findings: During an observation and concurrent interview on 10/16/2024 at 11:35 a.m. Certified Nursing Assistant 6 (CNA 6) was observed seated in the facility communal dining area monitoring residents as the residents watched Television. During an interview CNA 6 stated CNA 6 was covering for the Activities Director (AD) who was on vacation starting 10/15/2024. CNA 6 stated it was CNA 6's first day covering for the AD and that CNA 6 was trained on resident activities. CNA 6 stated CNA 6 was handed a guide (name not provided) on which activities to conduct with the residents. During an interview on 10/16/2024 at 11:38 a.m., the Director of Staff Development (DSD), stated CNA 6 was covering activities for the AD who was currently on vacation. The DSD also stated CNA 6 had not received training on how to conduct any activities with/for the residents. During an interview on 10/18/2024 at 4:59 p.m., the Director of Nursing (DON) stated the AD was on vacation since 10/15/2024. The DON stated activities help to keep residents' minds active and from further decline. The DON stated CNA 6 had worked with the AD in the past (unable to provide dates). The DON stated the DON did not know where the activity logs were kept. The DON stated the (DON) searched for the activities but could not find them. During a review of the facility's undated AD Job Description indicated, the AD, is responsible for planning, organizing, developing, and directing the overall operations of the Activities Department, responsible for directing and managing an on-going program of activities designed to meet in accordance with assessments, the interest, and the physical, mental, and psychosocial well-being of all Residents. Qualifications include: Associate degree or two years of college level course experience required. Must be a qualified therapeutic recreation specialist or an activities professional who is licensed by the appropriate state and is eligible for said certifications or Must have a minimum of 2 yrs experience in a social or recreation program within the last 5 years . 055711 Page 6 of 27 055711 10/18/2024 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 - Few 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 ensure that the residents right to formulate an advanced directive (a legal document indicating resident preference on end-of-life treatment decisions) was recorded for two of 14 sampled residents (Residents 23 and 26). This deficient practice violated Residents 23 and 26 right to be fully informed of the option to formulate advance directives and had the potential to cause conflict with health care wishes for residents 23 and 26. Findings: During a review of Residents 23's admission Record indicated the facility admitted Resident 23 on 3/8/2023 with diagnoses including hyperlipidemia (high level of fats in the blood), hypertension (HTN - elevated blood pressure), and generalized muscle weakness (lack of physical or muscle strength). During a review of Resident 23's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/9/2024, indicated Resident 23 had intact cognitive (mental action or process of acquiring knowledge and understanding) skills. The MDS indicated Resident 23 was dependent on staff for toileting, shower, chair to bed transfer and personal hygiene. During a review of Resident 23's Advanced directive acknowledgement form dated 3/8/2023 sign portion stated verbal. During an interview on 10/16/2024, at 8:59 A.M., with Resident 23, Resident 23 stated the facility did not discuss advanced directive information with him. During an interview and record review on 10/16/2024, at 11:10 AM., with the Social Services Director (SSD), the SSD stated the advanced directive acknowledgement form needs to have the residents' signature to be complete and accurate, the signature of the residents acknowledges the receipt of the information given. During a review of Residents 26's admission Record indicated the facility admitted Resident 26 on 9/21/2024 with diagnoses including hyperlipidemia, hypertensive chronic kidney disease (a condition where blood pressure damages the kidneys, making it difficult for kidneys to filter blood), and generalized muscle weakness. During a review of Resident 23's MDS dated [DATE], indicated Resident 26 had intact cognitive skills. The MDS indicated Resident 26 was dependent on staff for toileting, shower, chair to bed transfer and personal hygiene. During a review of Resident 23's Advanced directive acknowledgement form dated 3/8/2023 the signature and dated sections were blank. During a concurrent interview and record review, on 10/16/2024, at 10:16 AM., with Resident 26, Resident 26's Advanced directive acknowledgement form, dated 9/21/2024 was reviewed. Resident 26 stated the facility did not discuss advanced directive information with him. 055711 Page 7 of 27 055711 10/18/2024 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 - Few During an interview and record review on 10/16/2024, at 11:10 AM., with the SSD, the SSD stated the advanced directive acknowledgement form needs to have the residents' signature and date to be complete and accurate, the signature of the residents acknowledges receipt of the information given. During an interview on 10/18/2024, at 5:20 PM., with the Director of Nursing (DON), the DON stated advanced directives ensure that the wishes of the resident are made known to the facility. The DON stated, lack of an advanced directive or advanced directive acknowledgement form can lead to the facility missing out on what the residents' wishes are ultimately provide care that is not according to the residents wishes. During an interview on 10/18/2024, at 5:40 PM., with the Facility Administrator (FA), the FA stated advanced directives need to be completed by social services. The FA stated Advanced directives or advanced directive acknowledgment form lets the facility know the healthcare wishes of the resident and if not completed may lead to care that does not follow the residents wishes. During a review of facility's undated policy and procedures titled Advanced Directive, indicated, it is the policy of the facility to promote a resident's right to accept or refuse medical or surgical treatment, and the right to formulate an advanced directive .upon admission, all residents and representatives are presented with written information about their rights to .formulate an advanced directive. 055711 Page 8 of 27 055711 10/18/2024 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** Based on interview and record review, the facility failed to ensure one of eight sampled residents (Resident 164's) medical records had accurately documented assessment reflective of the resident's use of an anticoagulant (a substance that prevents or treats blood clots in the heart and blood vessels [tubes that carry blood throughout the body]). Residents Affected - Few This deficient practice resulted in Resident 164's medical records being inaccurate and missing vital information of services being rendered to the resident. Findings: During a review of Residents 164's admission Record indicated the facility admitted Resident 164 on 10/1/2024 with diagnoses including Major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), atrial fibrillation (Afib- an irregular heartbeat that occurs when the electrical signals in the hearts upper chambers fire rapidly and out of synch with the lower chambers), and dysphagia (difficulty swallowing safely). During a review of Resident 164's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 10/4/2024, indicated Resident 164 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 164 was dependent on staff for toileting, shower, chair to bed transfer and personal hygiene. The MDS further indicated Resident 164 had a diagnosis of Afib however, however, the MDS did not indicate Resident 164 was on anticoagulant. During a review of Resident 164's physicians orders dated 10/1/2024, indicated, Apixaban (medication used to treat blood clots) 5miligrams (mg -unit of measure) by mouth two times a day for deep vein thrombosis (DVT -a condition that occurs when a clot forms in a large vein deep in the body) prophylaxis (preventative treatment against disease). During a concurrent interview and record review, on 10/18/2024, at 3:46 P.M., with MDS nurse, Resident 164's physician orders dated 10/1/2024 and MDS dated [DATE] were reviewed. MDS nurse stated MDS assessment is a comprehensive assessment for the care provided to the residents. MDS stated Resident 164 had an order for Apixaban, but it was not documented in the MDS assessment. MDS nurse stated apixaban should have been documented in the MDS so that the MDS reflective of the care that is being provided to the resident, total care. During an interview on 10/18/2024, at 5:20 P.M., with the Director of Nursing (DON), the DON stated MDS assessments need to be completed accurately and completely to determine the level of care the resident needs, coordinate care based on the assessment and ultimately help in formulating a plan of care that is resident specific. During a review of facility's policy and procedures dated 9/2023 title Resident Assessment, indicated, A comprehensive assessment of every resident need is made at intervals designated by OBRA and PPS requirements . 1. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team 055711 Page 9 of 27 055711 10/18/2024 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0641 conducts timely and appropriate resident assessments . Level of Harm - Minimal harm or potential for actual harm During a review of the Centers for Medicare and Medicaid Services (CMS- a federal agency that provides health coverage to millions of people) Resident Assessment Instrument (RAI) dated 10/2024, title High risk drug classes, indicated, check if an anticoagulant medication was taken by the resident at any time during the 7 day look back period (or since admission/entry or reentry if less than 7 days) . Residents Affected - Few 055711 Page 10 of 27 055711 10/18/2024 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 - Some 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 create a comprehensive care plan (a resident-specific plan with defined clinical goals and interventions used to manage identified medical issues or other areas of concern) to meet the needs of two of five sampled residents (Residents 58 and 164) by failing to: -Develop a care plan for Resident 58's psychotropic (a medication that affects behavior, mood, thoughts, or perception) medications and their targeted behavior of visual hallucinations for Resident 58. - Develop a care plan for Resident 164's activities and anticoagulant (medication used to prevent blood clots) medication. These deficient practices placed Residents 58 and 164 at increased risk for suboptimal care from facility staff in these care areas leading to diminished physical, mental, and psychosocial well-being. Findings: a. During a review of Resident 58's admission Record indicated an the facility admitted the resident on 9/26/2024 with diagnoses of dementia (a progressive state of decline in mental abilities) with psychotic disturbance (severe mental disorder that causes a person to lose touch with reality), anxiety disorder (a mental health condition with feeling of worry, anxiety, or fear interfering with one`s daily activities) and cognitive communication deficit (a disorder that affects a person's ability to communicate). During a review of Resident 58's Physician Orders, dated 9/26/2024, indicated the facility to administer the following medications to Resident 58: - Risperidone (an antipsychotic medication) 2 milligrams (mg- unit of measurement) by mouth at bedtime for psychosis manifested by visual hallucinations (involves seeing things that aren't real) - Seroquel (an antipsychotic medication) 25mg - give 3 tablets (for a total of 75mg) by mouth at bedtime for psychosis manifested by visual hallucinations. During a review of Resident 58's Skilled Nursing Facility admission History and Physical (H&P), dated 9/27/2024, indicated Resident 58 was recently hospitalized for progressive neurologic decline and has experienced a cognitive decline for the past 18 to 20 months. The H&P also indicated Resident 58 could make needs known but could not make medical decisions due to cognitive deficits and dementia. During a review of Resident 58's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/30/2024, indicated the resident was able to understand others and was able to make herself understood. The MDS also indicated the resident had severely impaired cognition (ability to think, read, learn, remember, reason, express thoughts and make decisions) and the resident was dependent upon staff for all activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS also indicated the 055711 Page 11 of 27 055711 10/18/2024 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0656 resident was diagnosed with dementia was receiving antipsychotic and antianxiety medication. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 58's Medication Administration Records (MAR) for 9/2024 and 10/2024, the MARs indicated Resident 58 received the following: Residents Affected - Some - 18 doses of Seroquel 200 mg from 9/27/2024 to 10/18/2024 - 18 doses of Risperidone 75 mg from 9/27/2024 to 10/18/2024 During a review of Resident 58's Care Plans on 10/17/2024 at 9 AM, indicated there were no individualized person-centered care plans with measurable objectives, monitoring, and a timetable to meet the needs that addressed the resident's use of Seroquel and Risperidone or for the behavior of visual hallucinations. During a concurrent interview and record review on 10/17/2024 at 10:20 AM, Resident 58's care plans and physician orders for Seroquel, and Risperidone were reviewed with Registered Nurse Supervisor 2 (RNS 2). RNS 2 stated Resident 58 was currently taking/receiving Seroquel and Risperidone. RNS 2 also stated Resident 58 did not have care plans that addressed Resident 58's indications for Seroquel or Risperidone. RNS 2 stated a care plan should be developed for any psychotropic medication. RNS 2 further stated we have to care plan the behaviors and side effects of the medication and it was possible for Resident 58 to have side effects or for the resident's behavior to go untreated if the medications were not care planned. During an interview on 10/18/2024 at 8:19 AM, MDS 1 stated Resident 58 should have care plans in place that address the use of antipsychotic medication. MDS 1 stated, it is important to care plan the manifestation, behaviors so that the particular symptom(s) can be treated effectively. During an interview on 10/18/2024 at 3:42PM, the Director of Nursing (DON) stated all psychotropic medications and the behaviors being treated by the psychotropics, should be care planned for. The DON stated potential outcome of not initiating a care plan is the lack of care and inability to deliver necessary interventions and monitoring for a resident. During a review of the facility's policy and procedures (P&P) titled, Antipsychotic Medication Use, revised 3/2023, the staff will observe, document, and report to the Attending Physician information regarding the effectiveness of any interventions, including antipsychotic medications. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, revised 3/2023, indicated, The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes. b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. A review of Residents 164's admission Record indicated the facility admitted Resident 164 on 10/1/2024 with diagnoses including Major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), atrial fibrillation (Afib- an irregular heartbeat that occurs when the electrical signals in the hearts upper chambers fire rapidly and out of synch with the lower chambers), and dysphagia (difficulty 055711 Page 12 of 27 055711 10/18/2024 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0656 swallowing safely). Level of Harm - Minimal harm or potential for actual harm A review of Resident 164's MDS dated [DATE], indicated Resident 164 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 164 was dependent on staff for toileting, shower, chair to bed transfer and personal hygiene. MDS further indicated Resident 164 had a diagnosis of Afib however, there MDS did not indicate that Resident 164 was on an anticoagulant. Residents Affected - Some A review of Resident 164's Physicians Orders dated 10/1/2024, indicated, Apixaban (used to treat health problems caused by a blood clot) 5miligrams (md -unit of measure) by mouth two times a day for deep vein thrombosis (DVT -a condition that occurs when a clot forms in a large vein deep in the body) prophylaxis (preventative treatment against disease). A review of Resident 164's MAR for 10/2024, indicated Resident 164 received a total of 32 doses of Apixaban 5mg from 10/1/2024 to 10/18/2024. During a concurrent interview and record review, on 10/18/2024, at 11:34 AM., with Registered Nurse Supervisor 1 (RNS 1), Resident 164's chart was reviewed. RNS 1 stated there was no care plan for activates and there was no care plan for apixaban. RNS 1 stated residents need to have care plan so the facility can provide overall and individualized care to the residents. During an interview on 10/18/2024, at 5:20 PM., with the Director of Nursing (DON), the DON stated residents need to have care plans to ensure that the resident is receiving appropriate care. The DON stated, if residents do not have a care plan, resident is not receiving patient centered care. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, revised 3/2023, indicated, The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes. b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 055711 Page 13 of 27 055711 10/18/2024 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0680 Ensure the activities program is directed by a qualified professional. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant 6 (CNA 6) was trained and had the appropriate qualifications to serve as a qualified therapeutic recreation specialist or an activities professional to support the physical, mental, and psychosocial well-being of 57 of 57 residents in the facility. Residents Affected - Few This deficient practice had the potential to result in a decline in the physical, mental, and psychosocial well-being the 57 residents. Findings: During an observation and concurrent interview on 10/16/2024 at 11:35 AM., CNA 6 was observed seated in the facility communal dining area monitoring residents as the residents watched Television. During an interview CNA 6 stated CNA 6 was covering for the Activities Director (AD) who was on vacation starting 10/15/2024. CNA 6 stated it was CNA 6's first day covering for the AD and that CNA 6 was trained on resident activities. CNA 6 stated CNA 6 was handed a guide (name not provided) on which activities to conduct with the residents. During an interview on 10/16/2024 at 11:38 AM., the Director of Staff Development (DSD), stated CNA 6 was covering activities for the AD who was currently on vacation. The DSD also stated CNA 6 had not received training on how to conduct any activities with/for the residents. During an interview on 10/18/2024 at 4:59 PM., the Director of Nursing (DON) stated the AD was on vacation since 10/15/2024. The DON stated activities help to keep residents' minds active and from further decline. The DON stated CNA 6 had worked with the AD in the past (unable to provide dates). The DON stated the DON did not know where the activity logs were kept. The DON stated the (DON) searched for the activities but could not find them. During a review of the facility's undated AD Job Description indicated, the AD, is responsible for planning, organizing, developing, and directing the overall operations of the Activities Department, responsible for directing and managing an on-going program of activities designed to meet in accordance with assessments, the interest, and the physical, mental, and psychosocial well-being of all Residents. Qualifications include: Associate degree or two years of college level course experience required. Must be a qualified therapeutic recreation specialist or an activities professional who is licensed by the appropriate state and is eligible for said certifications or Must have a minimum of 2 yrs experience in a social or recreation program within the last 5 years . 055711 Page 14 of 27 055711 10/18/2024 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to develop a care plan (a document outlining a detailed approach to care customized to an individual resident's need) with measurable goals and interventions to address care and treatment of a resident with dementia (a disorder of mental processes caused by brain disease or injury and marked by memory disorder, personality changes, and impaired reasoning) for one of one sampled resident (Resident 58). Residents Affected - Few This deficient practice had the potential to negatively affect the delivery of services to Resident 58. Finding: A review of Resident 58's admission record indicated the facility admitted Resident 58 on 9/26/2024 with diagnoses that included dementia (a progressive state of decline in mental abilities) with psychotic disturbance anxiety disorder (a mental health condition with feeling of worry, anxiety, or fear interfering with one`s daily activities) and cognitive communication deficit (a disorder that affects a person's ability to communicate). A review of Resident 58's Physician Orders, dated 9/26/2024 indicated: 1.Risperidone (medication to treat psychotic disturbance anxiety) 2 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) by mouth at bedtime for psychosis manifested by visual hallucinations 2.Seroquel (medication used to treat psychosis) 25mg 3 tablets (for a total of 75mg) by mouth at bedtime for psychosis manifested by visual hallucinations A review of Resident 58's History and Physical (H&P) dated 9/27/2024, indicated the resident was recently hospitalized prior to admission for acute or chronic functional decline, progressive neurologic decline due to concerns for catatonia ( a condition in which a person is awake but does not seem to respond to other people and their environment and is characterized by abnormal movements, behaviors and withdrawals). The H&P also indicated during the hospitalization Resident 58 was noted to be wandering around, was restless and had abnormal stiffness and posture. The H&P further indicated the resident had experienced a cognitive decline for the past 18 to 20 months, was having hallucinations since early 2024. The H&P further indicated Resident 58 could make needs known but could not make medical decisions due to cognitive deficits and dementia. A review of Resident 58's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/30/2024, indicated the resident was able to understand others and was able to make himself understood. The MDS also indicated the resident had severely impaired cognition (ability to think, read, learn, remember, reason, express thoughts and make decisions). Resident 58 was dependent upon . The MDS also indicated the resident was diagnosed with dementia was receiving antipsychotic and antianxiety medication. During an observation of Resident 58 on 10/15/2024 at 8:56 AM, at Resident 58's bedside, Resident 58 was observed in bed with the head of bed elevated. Resident 58 had a flat affect, was still with hands posed in the air and her answers to questions were limited to one word answers. 055711 Page 15 of 27 055711 10/18/2024 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 58's nurses progress note, dated 10/15/2024, indicated the resident was seen by the attending physician and the resident's order for Ativan (medication to relieve anxiety) was decreased from 1 milligram (mg-Unit of measurement) to 0.5mg at bedtime. A review of Resident 58's Physician Orders, dated 10/16/2024 indicated to administer Ativan 0.5 mg every 12 hours until 10/20/2024 and at bedtime for catatonia manifested by rigidity. A review of Resident 58's Care Plans on 10/17/2024 at 9:00AM, indicated there was no individualized person-centered care plan for the resident's dementia care which included measurable objectives, monitoring, and a timetable to meet resident's needs. A review of Resident 58's September and October 2024 Medication Administration Records ((MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) indicated the resident received the following: 1.eight doses of Ativan 0.5 mg from 9/27/2024 to 10/18/2024 and 2.five doses of Ativan 1mg from 9/27/2024 to 10/18/2024 3.18 doses of Seroquel 200 mg from 9/27/2024 - 10/18/2024 4.18 doses of Risperidone 75 mg from 9/27/2024 - 10/18/2024 During a concurrent interview and record review on 10/17/2024 at 10:10 AM, Resident 58's electronic medical chart was reviewed with Registered Nurse Supervisor (RNS) 2. RNS 2 stated Resident 58 has diagnoses of anxiety disorder and dementia. RNS 2 further stated Resident 58 did not have any care plan with measurable goals and interventions that addressed the resident's diagnosis of dementia or cognitive skills. RNS 2 was unable to provide documented evidence the licensed nursing staff identified and/or assessed specific behaviors or episodes . During an interview on 10/18/2024 at 3:41 PM, the Director of Nursing (DON) stated Resident 58 should have a dementia care plan in order to address the care the resident receives. The DON stated the care plan would include the behavioral interventions one would implement in caring for a resident with dementia. A possible outcome of not having a dementia care would be the resident would not receive the care needed. During a review of the facility's policy and procedures (P&P) titled Management of Dementia, undated, the P&P indicated it was the facility's policy that residents with indications of dementia receive appropriate interventions or treatment based on clinical symptoms. The P&P further indicated For the individual with confirmed dementia, the staff and physician will identify a plan to maximize remaining function and quality of life. 055711 Page 16 of 27 055711 10/18/2024 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 interview and record review, the facility failed to provide appropriate monitoring of anticoagulants (blood thinner; a substance that hinders the clotting of blood) and antidepressants (medication used to treat depression [mental health that involves persistent feeling of sadness, loss of interest and low mood that lasts for a long time] for two of ten sampled residents (Resident 6 and Resident 164). Residents Affected - Some These deficient practices had the potential to result in complications from the use of antidepressants and anticoagulants such as bruising, bleeding to Resident 6 and Resident 164. Findings: 1.A review of Resident 6's admission Record indicated the facility originally admitted the resident on 2/13/2020 and re-admitted the resident on 11/1/2023 with diagnoses including atrial fibrillation (AFib - an irregular often rapid heart rate that commonly causes blood clots), transient ischemic attack and cerebral infarction (damage to brain tissues caused by lack of oxygen to the area). A review of the physician order, dated 2/8/2023, indicated staff were to monitor Resident 6 for signs and symptoms of bleeding including prolonged bleeding in the nose, eyes, gums, bruises that don't heal, blood in the urine and black tarry stool. The physician order further indicated staff were to notify the physician if there was bleeding every shift due to use of Eliquis. A review of the Physician's Order, dated 4/4/2023, indicated Resident 6 was to receive Eliquis (medication used to prevent blood clots) 5 milligrams (mg, unit of measurement) by mouth two times a day with breakfast and dinner for AFib. A review of the care plan titled, potential for bleeding, bruising and/or skin discolorations, developed 11/2/2023 indicated Resident 6 was at risk due to the use of anticoagulant therapy secondary to diagnosis of a-fib. A review of the care plan indicated the goals was for the resident to have no episodes of bleeding. The care plan interventions included: 1.To monitor for bruising or bleeding every shift 2.To monitor for blood in the urine or stool 3. Notify the physician of signs of bleeding and 4. To use a soft toothbrush for brushing and watch for any gum bleeding. A review of Resident 6's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 8/7/2024, indicated the resident's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making were moderately impaired. The MDS also indicated Resident 6 required partial assistance to set up assistance with dressing, eating and toileting hygiene and bathing. The MDS further indicated the resident was taking an anticoagulant. During a record review on 10/18/2024 at 7:25 AM, the October 2024 medication administration records ((MAR - a daily documentation record used by a licensed nurse to document medications and 055711 Page 17 of 27 055711 10/18/2024 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some treatments given to a resident), Resident 6 received Eliquis twice a day. A review of the MAR also indicated no documented evidence the licensed nurses monitored for side effects of Eliquis. During a concurrent interview and record review on 10/18/2024 at 8:13 AM, Resident 6's electronic chart physician orders and MAR were reviewed with the MDS Nurse. MDS Nurse stated Resident 6 was currently taking Eliquis. The MDS Nurse stated there was no order for the monitoring for side effects or bleeding related to the use of Eliquis. MDS stated Resident 6 previously had an order, but it was not carried over when she was re-admitted in November 2023. The MDS Nurse stated staff should monitor for bleeding and there was a high risk for bruising. During an interview on 10/18/2024 at 3:43 PM, the Director of Nursing (DON) stated it is the facility's practice to monitor for bleeding and bruising for those residents' taking anticoagulants. The DON stated the nursing staff should have monitored Resident 6's for bleeding and bruising and document it on the MAR. The DON stated a potential outcome of not monitoring for the side effects of Eliquis was Resident 6 could have an episode of sudden bleeding. According to the Nurse's Drug Handbook, 2022, Eliquis side effects included bleeding and excessive bleeding leading to hemorrhage. The Nursing Drug Handbook indicated to monitor closely for bleeding as Eliquis may cause life-threatening bleeding. During a review of the facility's policy and procedures (P&P) titled, Anticoagulation- Clinical Protocol, reviewed 4/2024, the P&P indicated the staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems. a. If an individual on anticoagulation therapy shows signs of excessive bruising, hematuria, hemoptysis, or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant. 2. A review of Residents 164's admission Record indicated the facility admitted Resident 164 on 10/1/2024 with diagnoses including major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), Afib., and dysphagia (difficulty swallowing safely). A review of Resident 164's MDS dated [DATE], indicated Resident 164 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The same MDS indicated Resident 164 was dependent on staff for toileting, shower, chair to bed transfer and personal hygiene. The same MDS further indicated Resident 164 had a diagnosis of Afib however, there MDS did not indicate that Resident 164 was on an anticoagulant. A review of Resident 164's physicians orders dated 10/1/2024, indicated: Apixaban (used to treat health problems caused by a blood clot) 5mg by mouth two times a day for deep vein thrombosis (DVT -a condition that occurs when a clot forms in a large vein deep in the body) prophylaxis (preventative treatment against disease), mirtazapine 30mg one tablet by mouth at bedtime for depression manifested by poor by mouth intake and escitalopram 5mg one tablet by mouth one time a day for depression manifested by poor by mouth intake. A review of Resident 164's care plan dated 10/2/2024, indicated Medication: Escitalopram, Mirtazapine . Interventions; assess/record effectiveness of drug treatment, monitor and report signs and symptoms of sedation . 055711 Page 18 of 27 055711 10/18/2024 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent interview and record review, on 10/18/2024, at 11:50 A.M., with Registered Nurse Supervisor (RNS) 1, Resident 164's physician orders dated 10/1/2024, care plans and MAR for 10/2024 were reviewed. RNS 1 stated, apixaban is an anticoagulant that requires facility to monitor residents of any signs and symptoms of bleeding, finding or lack thereof need to be documented on the MAR every shift. RNS 1 stated monitoring for signs and symptoms of bleeding is part of the facility protocol batch that needs to be ordered automatically by the nursing staff whenever there is an order for anticoagulant for a resident. RNS 1 stated Resident 164 did not have an order to monitor for signs and symptoms of bleeding and therefore there was no monitoring for the apixaban on the MAR that was only be triggered once the order to monitor for bleeding was entered in the orders. RNS 1 states not monitoring for bleeding may lead to possibility of resident bleeding and alter the overall wellbeing of the resident. RNS 1 stated needs to monitor antidepressants so that the facility may not miss any behaviors and their frequency which can ultimately give guidance as to when a medication needs to be discontinued or adjusted. Not monitoring the side effects of the medication can lead to residents' care not being met. During an interview on 10/18/2024, at 5:20 P.M., the DON stated the facility needs to monitor residents that are on anticoagulants and antidepressants, documents the findings on the MAR. The DON stated lack of monitoring and documenting findings for residents on anticoagulants may lead to bleeding that may go unnoticed and possible anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy oxygen carrying blood cells) and hospitalization. The DON further stated resident on antidepressants need to be monitored for behaviors and side effects which need to be documented on the MAR. If there is no monitoring for antidepressants, side effects and behaviors may not be captured, and dosing may not be adjusted appropriately. A review of the facility's P&P titled, Antipsychotic Medication Use, reviewed 3/2023, the P&P indicated The staff will observe, document, and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician. 055711 Page 19 of 27 055711 10/18/2024 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 - Some 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 observation, interview, and record review, the facility failed to ensure the facility document titled, Facility Verification of Informed Consent, (a principle in medical ethics, medical law, and media studies, that a patient must have sufficient information and understanding before making decisions about their medical care) form was fully completed and properly executed for psychotropic (medications that affect the mind, emotions, and behavior) medication for two of five sampled residents (Residents 58 and 164). This deficient practice had the potential for Residents 58 and 164 not to be fully informed of the risk and benefits of the psychotropic medication they were receiving. Findings: a. A review of Resident 58's admission record indicated Resident 58 was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities) with psychotic disturbance anxiety disorder (a mental health condition with feeling of worry, anxiety, or fear interfering with one`s daily activities) and cognitive communication deficit (a disorder that affects a person's ability to communicate). During a review of Resident 58's Physician Orders (PO), dated 9/26/2024 , the PO indicated: risperidone (medication used to treats psychosis [a severe mental condition in which thought, and emotions are so affected that contact is lost with reality] 2 milligrams (mg, unit of measurement) by mouth at bedtime for psychosis manifested by visual hallucinations; Seroquel (medication to treat psychosis) 25mg 3 tablets (for a total of 75mg) by mouth at bedtime for psychosis manifested by visual hallucinations During a review of Resident 58's History and Physical (H&P), dated 9/27/2024, the H&P indicated Resident 58 was recently hospitalized for acute or chronic functional decline, progressive neurologic declined and has experienced a cognitive decline for the past 18 to 20 months. The H&P also indicated Resident 58 could make needs known but could not make medical decisions due to cognitive deficits and dementia. A review of Resident 58's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/30/2024, indicated Resident 58 was able to understand others and was able to make himself understood. The MDS further indicated the resident had severely impaired cognition (ability to think, read, learn, remember, reason, express thoughts and make decisions). Resident 58 was dependent upon. The same MDS indicated the Resident 58 was diagnosed with dementia was receiving antipsychotic and antianxiety medication. A review of Resident 58's Physician Orders dated 10/16/2024 indicated Ativan (an anti-anxiety medication) 0.5 mg every 12 hours until 10/20/2024 and at bedtime for catatonia (a condition in which a person is awake but does not seem to respond to other people and their environment and is characterized by abnormal movements, behaviors, and withdrawals) manifested by rigidity. A review of Resident 58's September and October 2024 Medication Administration Records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a 055711 Page 20 of 27 055711 10/18/2024 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0758 resident) indicated the resident received the following: Level of Harm - Minimal harm or potential for actual harm 1. eight doses of Ativan 0.5 mg from 9/27/2024 to 10/18/2024 and 2. five doses of Ativan 1mg from 9/27/2024 to 10/18/2024 Residents Affected - Some 3. 18 doses of Seroquel 200 mg from 9/27/2024-10/18/2024 4. 18 doses of Risperidone 75 mg from 9/27/2024-10/18/2024 A review of Resident 58's anti-anxiety medication care plan, developed 10/16/2024, indicated Resident 58 was receiving Ativan for anxiety manifested by catatonia syndrome. The care plan interventions included to document and notify physician if mood state interferes with functioning, develop a meaningful activity for the resident while in the facility to divert attention. During a concurrent interview and record review of Resident 58's active chart on 10/17/2024 at 10:50 AM, a Facility Verification of Informed Consent to Physical Restraints Psychotherapeutic Drug or prolonged use of Active Device Form (Verification of Informed Consent) for Ativan, Risperidone, and Seroquel was reviewed with Registered Nurse Supervisor (RNS) 2. RNS 2 stated all three medications were listed out on the one Verification of Informed Consent Form. RNS 2 confirmed and stated the form was not completed correctly. RNS 2 stated each medication should have its own form and the dosage and frequency should also be written on the form. RNS 2 stated psychotropic medications are high risk medications and the Verification of Informed Consent Form's is used to inform the resident and or family of the medications side effects and risks. During an interview on 10/18/2024 at 4:37 PM, the Director of Nursing (DON) stated Resident 58's form was completed incorrectly. The DON stated each medication should have its own individual form. The DON further stated the medication's dosage, frequency and diagnosis should be written out on an individual form. The DON stated the purpose of obtaining informed consent before administering psychotropic medication was to ensure the resident is aware of the risks and benefits of the medication and so the resident can be monitored for any effects of taking the medication. The DON further stated an incorrectly executed Informed consent could lead to the resident being unaware of the medication or dosage they were taking. b. A review of Residents 164's admission Record indicated the facility admitted Resident 164 on 10/1/2024 with diagnoses including Major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), atrial fibrillation (Afib- an irregular heartbeat that occurs when the electrical signals in the hearts upper chambers fire rapidly and out of synch with the lower chambers), and dysphagia (difficulty swallowing safely). A review of Resident 164's MDS dated [DATE], indicated Resident 164 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The same MDS indicated Resident 164 was dependent on staff for toileting, shower, chair to bed transfer and personal hygiene. A review of Resident 164's physicians orders dated 10/1/2024, indicated: Mirtazapine (medication to treat depression) 30mg one tablet by mouth at bedtime for depression 055711 Page 21 of 27 055711 10/18/2024 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 - Some manifested by poor by mouth intake and Escitalopram 5mg one tablet by mouth one time a day for depression manifested by poor by mouth intake. During a concurrent interview and record review, on 10/18/2024, at 11:34 A.M., with RNS 1, Resident 164's Facility Verification of Informed Consent to Physical Restraints Psychotherapeutic Drug or prolonged use of Active Device Form (Verification of Informed Consent) dated 10/1/2024 was reviewed. RNS 1 stated informed consent needs to be accurately completed reflecting the dose, route, frequency of the medication and each medication needs not have its own informed consent. RNS 1 stated not filling out the consent form accurately may lead to medication errors. During a concurrent interview and record review, on 10/18/2024, at 5:20 P.M., with DON, Resident 164's Facility Verification of Informed Consent to Physical Restraints Psychotherapeutic Drug or prolonged use of Active Device Form (Verification of Informed Consent) dated 10/1/2024 was reviewed. The DON stated consent forms for antipsychotics should not have two medications on one form, each medication needs to have its own consent form that also includes the dose, diagnosis, and behaviors to be treated. DON states inaccurate informed consents forms may lead to resident not knowing that they are taking the medication. DON stated residents needs to be able to have the choice or right to make the decision to take the medication and the dose being prescribed. During a review of the facility's policy and procedures (P&P) titled Informed Consent - Psychotherapeutic Medications and Restraint Devices revised 12/14/2023, the P&P indicated the healthcare practitioner ordering psychotherapeutic medication is responsible for Providing documentation that informed consent was obtained, including the diagnosis/clinical indications for the medication, Ordering psychotherapeutic (chemical) restraint medication and obtaining informed consent for the dosage range/specific dosage for each consent and obtaining informed consent from the resident/surrogate decision maker Prior to receipt of the medication when a psychotherapeutic medication is ordered throughout the resident's stay in the facility. 055711 Page 22 of 27 055711 10/18/2024 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0760 Ensure that residents are free from significant medication errors. 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 failed to obtain a physician's order and clinical indication to apply medication for one of 13 sample residents (Resident 53). Residents Affected - Few This deficient practice resulted in Resident 53 applying the antifungal powder under the breasts without a physician's order and clinical indication for the antifungal powder. Cross Reference F554 Findings: During a review of the admission record indicated Resident 53, was admitted to the facility on [DATE], with diagnoses including acute respiratory failure with hypoxia (a serious medical condition that occurs when the lungs have trouble loading the blood with enough oxygen and body tissues), congestive heart failure (a serious condition that occurs when the heart can't pump enough blood to meet the body's needs), major depressive disorder (a mental health condition that involves persistent feelings of sadness, hopelessness, and a loss of interest in activities), and muscle weakness and dysphagia (medical term for swallowing difficulties). During a review of Resident 53's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 09/21/2024, indicated Resident 5's cognition (The mental ability to make decision of daily living) was intact. The MDS indicated Resident 53 was independent with eating, oral hygiene, and required partial moderate assistance with upper body dressing, was dependent for Toileting hygiene, shower/bathe, lower body dressing, required limited assistance with his activities of daily living. During a concurrent observation and interview on 10/15/2024, at 7:56 AM, Resident 53's bedside drawer was observed with unlabeled medication dispensing cup and a white powder like substance inside the medication dispensing cup. Resident 53 was asked if she knew what the white powder that was inside the unlabeled medication cup. Resident 53 stated, it is antifungal (medication to treat fungal infection/s) powder and that she applies the powder under her breast. During an interview on 10/15/2024, at 7:56 AM., Certified Nursing Assistant 5 (CNA5) stated CNA 5 did not know what was in the medicine cup. CNA5 further stated, it looks like a powder the white powdered substance. During an interview on 10/15/2024 at 8 AM., with the Treatment Nurse 1 (TXN 1), TXN 1 stated TXN 1 did not know what the white powdered substance in the medication dispensing cup on top of Resident 53's bedside drawer was. TXN 1 further stated, the powder in the medication cup is not supposed to be on top of resident's bedside drawer, because it is not labeled and thus unidentifiable. TXN 1 also stated leaving an unlabeled medication cup with an unidentifiable powder in places the Resident at risk of ingesting a white powder that may be unsafe for consumption and if consumed could cause an allergic reaction that could result in anaphylaxis and even death. During an interview on 10/18/2024 at 4:53 PM., with the Director of Nursing (DON), the DON stated, Residents are only allowed for have medications at bedside if they have been assessed to be cognitively intact and have physically demonstrated that they can safely be able to do so and have a physician approval. The DON stated without resident assessment, the medication may be applied/administered 055711 Page 23 of 27 055711 10/18/2024 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0760 Level of Harm - Minimal harm or potential for actual harm incorrectly, placing the resident at risk for skin breakdown, irritation, and or redness. The DON also stated medication at bedside should be secured in a locked container. During a review of the Physician Orders dated 10/18/2024, indicated no order to apply antifungal powder under Resident 53's breasts. Residents Affected - Few During a review of Resident 53's Medication Administration Record (MAR) for 10/2024, indicated no order to apply antifungal powder under Resident 53's breasts. During a review of the facility's policy and procedures titled Self-Administration of Medication dated 09/2023 indicated, .the IDT, assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the Resident. Policy further states self-administered medications are stored in a safe and secure place, which is not accessible by other Residents . 055711 Page 24 of 27 055711 10/18/2024 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure safe food storage practices in the kitchen for by failing to ensure expired canned food, corned beef hash 6-pound (lbs., unit of measurement) 12 ounce (oz, is a unit of measurement) was not stored in the same location as non-expired food to be served to residents in the food storage area along with all other canned foods not expired. The corned beef hash was expired on 10/2022. This deficient practice had the potential to result in harmful bacteria growth and the consumption of spoiled food that could lead to foodborne illness (caused by contamination of food and occur at any stage of the food production, delivery, and consumption chain) in 57 of 57 residents who received food from the kitchen. Findings: During an interview and a concurrent observation of the walk-in food storage area on 10/15/2024 at 7:10 AM, the Dietary Supervisor (DS) confirmed the findings and stated expired canned food should be separated from the non-expired food. Some dented cans were also observed. The DS stated the observed expired food should have been separated to ensure that residents are not served expired food. The DS stated that expired food should not be served to the residents because they are elderly and have medical conditions and eating expired food could make them sick and cause digestive issues. During a review of the facility's policy and procedures (P&P) titled Damaged Cans and Packages to be Returned to Vendor, dated 1/1/2017 and revised on 1/1/2018, the P&P indicated under Regulation/Surveyor Guidance- Store, prepare, distribute and serve food in accordance with professional standards for food service safety.Procedure: 1. All foods delivered require inspection 4.Place all damaged goods in specified area labeled Return to Vendor Do Not use . The location of this area is in the storeroom .6. Discard if vendor doesn't want to see product. During a review of the facility's P&P titled Storage of Food and Supplies, dated 2017 and 2018, the P&P indicated Policy: Food and supplies will be stored properly and in safe manner .Procedures for Dry Storage: 8. Food stored should be arranged in food groups to facilitate storing, locating and taking inventories. Similar items such as cereals or fruits should be grouped and alphabetized withing group. (Have a separate area labeled for dented cans and damaged food items.) Labels should be visible, and the arrangement should permit rotation of supplies so that oldest items will be used first. All food will be dated - month, day, year. All food products will be used per the times specified in the .Dry Food Storage Guidelines, in this Policy and Procedure Book. The storage times in the guidelines are intended to be on the safe side .Exception: If you have product information about specific items, (ie., spices, condiments, baking mixes) allowing a longer shelf life than the one in the Dry Food Storage Guidelines, you can use that storage time instead. Keep that documentation on hand in case you are asked for it. No food will be kept longer than the expiration date on the product. 055711 Page 25 of 27 055711 10/18/2024 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. 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 provide a homelike environment by failing to ensure a pest free environment for one of six sampled residents (Resident 214). Residents Affected - Some This deficient practice resulted in Resident 214 being bitten by ants and a potential of a facility wide infestation of ants and other residents being affected by a wider infestation. Findings: A review of Resident 214's admission Record indicated Resident 214 was admitted to the facility on [DATE], with diagnoses that included, anxiety disorder, (restlessness, worried, tense, or afraid of what may happen in the future), muscle weakness (a lack of physical or muscle strength, throughout the body). A review of Resident 214's Minimum Data Set (MDS - a federally mandated resident assessment tool), indicates Resident 214's cognition (the mental ability to make decisions of daily living) was intact, and can make decisions for medical care and perform all activities of daily living. During a concurrent observation and interview on 10/15/24 at 10:43 AM Resident 214 stated there were ants on the wall and at the bottom of the door that leads outside to the rear of the facility from Resident 214's room. During an observation it was noted that ants were crawling on the side of the wall just inside the sliding glass door that leads outside the resident's room to the back walkway of the facility. It was observed that ants were also crawling on the floor just inside the sliding glass door that leads to the back walkway of the facility. During an observation and a concurrent interview on 10/15/24 at 10:55 AM, the Maintenance Supervisor (MS) stated just yesterday, the facility had fumigation services for ants and pests to the outside and inside of the facility. The MS confirmed there were ants in Resident's 214's room. The MS stated that he would do a room to room check of the facility to ensure a homelike environment free of pests. During a review of the facility document titled, Total Maintenance Service Invoice #:14025, dated 10/14/2024 at 9:05 am, the document indicated the following: Performed exterior treatment around facility for heavy ant activity. 4 colonies found in trees by sidewalk. All colonies were treated, please give 72 hours for chemical to fully take effect. Also, interior unites 1, 14, staff lounge, doctors office/lounges, dining, and nurse stations were all bated for ants. Also, interior kitchen was serviced, and no roaches found. Rodent devices have been checked and no mice captured or signs of pest. Fly, light has also been serviced and glue boards replaced. During an interview on 10/16/24 at 2:13 PM, the MS stated he had to spray the ants inside the resident's room himself since the Fumigation company would take at least 24 hours to return. During an interview on 10/18/24 at 2:24 PM, the Director of Nursing (DON) stated fumigation services was called a few days ago for ants reported outside the building. Fumigation company has already sprayed for bugs on the perimeter of the facility. There was no spaying for insects inside the building only on the outside of the facility. Because ants have been discovered inside the facility the staff will do a room to room check for insects and then, if necessary, we will call the fumigation 055711 Page 26 of 27 055711 10/18/2024 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some company to come out to spray inside the facility. The DON stated that residents should be able to live in a pest free environment and it was the responsibility of the facility to ensure their rooms and living areas are always pest free. During a review of the facility's policy and procedures (P&P) titled, Homelike Environment revised 9/2023, the P & P indicated Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible .Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. 055711 Page 27 of 27