Health inspection·December 4, 2025

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the failed to ensure that one of two sampled resident (Resident 34) was provided with alternative meal/s that was appealing, nutritional, and appetizing. This deficient practice had the potential to result in the resident missing a meal, that could lead to weight loss. A review of Resident 34's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included Malignant Neoplasm of Colon (Abnormal Cell growth in the colon (the final part of the digestive system that absorbs water, from digested food), which may lead to tumors (a lump or mass of extra cells that grow abnormally in the body) in the colon, anemia (blood disorder in which the blood has a reduced ability to carry oxygen to the rest of the body), and muscle weakness (a reduced ability to accomplish everyday tasks). ? A review of Resident 34's Minimum Data Set (MDS - a resident assessment tool, and care-screening tool) dated 7/1/2025, indicated that Resident 34's cognition (mental ability to make decisions of daily living) was intact. ? A review of Resident 34's history and physical (H&P) dated 6/30/2025 indicated Resident 34 could make decisions for activities of daily living. ? During an interview on 12/1/2025, at 10:18am, Resident 34 stated that she was having a difficult time with the food in the facility because she needs a vegetarian diet. Resident 34 stated she is allergic to gluten, oats, and corn, she does not like peas, lentils, fish, eggs, or milk; because those foods make her nauseous (to feel like vomiting), she gets swollen legs, feet and ankles. Resident 34 stated she only gets bread and cheese as alternatives, and she gets noodles about three or four days out of the week. Resident 34 stated she has been recently in cancer remission, is unable to eat certain foods, and is trying to pursue a vegetarian lifestyle to improve her health. During an interview on 12/1/2025, at 12:45pm, Certified Nursing Assistant (CNA) 2 stated, Resident 34 often has difficulty with the food served in the facility and would normally have her own food. CNA2 If Resident 34 eats the facility food then she will usually have the alternative plate, or the kitchen will give her something special. CNA 2 stated, either way, I often go back to ask if they have alternatives to give to (Resident 34), usually the kitchen gives her something she can eat.? ? During an interview on 12/1/2025, at 12:53pm, the Rehabilitation Services Director (RSD) stated that the facility Administrator gave RSD the okay to order food from a restaurant for Resident 34, due to the kitchen staff's inability to accommodate her need for an alternative food choice for lunch. Resident 34 stated, ?This happens very often, because the kitchen will bring the resident food that she cannot eat. ?During observation lunch and concurrent record review on 12/1/2025 at 1:05 PM, Resident 34's meal ticket was reviewed. the facility Resident 34 was served a food tray with noodles and red sauce and no other food items on the plate. A review of Resident 34's meal ticket on the tray, indicated, Noon Meal Mon-12/1/2025; Lemon Baked Chicken 2-OZ (ounces-unit of measurement), GF Spaghetti 1-#8 SCP (scoop), Buttered Spinach 1-#8 SCP, GF Garlic Bread 1-Each, Sherbet Cup 1-Each, Water 8-FL OZ, and Butter 1-Each. ? During an interview and Page 1 of 7 055711 055711 12/04/2025 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 - Few record review on 12/03/2025 at 1:58pm the Dietary Supervisor (DS) reviewed picture of Resident 34's lunch tray served on 12/1/2025. The DS stated Resident 34 refuses the food provided by the kitchen and states that she will throw up if she eats the meal. The DS stated Resident 34's food did not look appetizing and that the food on the tray was not the same as what was described on the meal ticket for Resident 34. ? During an interview on 12/03/2025 at 2:25pm the Administrator (Adm) stated, he will support Resident 34's needs as best he can while Resident 34 remains in the facility by providing outside food when in-house food is not tolerable or to her preferences.? ? During an interview on 12/04/2025 at 2:37pm the Director of Nursing (DON) stated, the lunch ticket or card describing what is being delivered for lunch is not accurate. The food on the tray should be the same as what is on the meal ticket.?? ? A review of the facility policy and procedures (P&P) titled Alternates on the Menu & Meal Substitution dated 01/10/2023, indicated, Policy: To utilize a menu that offers alternates (not to be confused with menu substitutions). These alternatives are for the residents to choose from when they choose not to eat the scheduled menu items. ? Procedure: 1. The Director of Food & Nutrition Services (DFNS) will provide alternates upon request in a timely fashion. 3. The DFNS places a slip on the tray card denoting that the resident has selected the alternate.? 5. The entree alternates will provide 3 oz protein or equivalent portion as specified on the menu for tat meal. 8. Residents who refuse the entire meal may be offered a meal substitute consisting of: a. Appropriate similar portion of protein foods plus vegetable or fruit salad/dessert to complete the meal; b. Therapeutic diets will be followed to the extent feasible. 055711 Page 2 of 7 055711 12/04/2025 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 observation, interview, and record review, the facility failed to ensure one of the two sampled residents (Resident 9) Preadmission Screening and Resident Review (PASRR - a screening evaluation used to determine whether placement in a long term care facility is appropriate for the resident) Level I (a tool that helps identify possible serious mental illness and/or intellectual/development disability) assessment was accurately completed. This deficient practice of failing to accurately complete PASRR Level I assessment for Resident 9, placed Resident 9 at increased risk to not receive the necessary/appropriate care and services. Findings: During a review of Resident 9's face sheet (admission Record- a document containing demographic and diagnostic information) indicated, Resident 9 was admitted to the facility on [DATE] with diagnoses including unspecified dementia with mood disturbance and anxiety (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems accompanied by emotional changes like depression [Is a mood disorder that causes a persistent feeling of sadness and loss of interest], anxiety, or irritability), and paranoid schizophrenia (a serious mental disorder characterized by prominent symptoms like intense paranoia, delusions [fixed, false beliefs not based in reality], and hallucinations [seeing, hearing, feeling things that are not there]). During a review of Resident 9's Minimum Data Set, (MDS - a resident assessment tool) dated 11/21/2024, indicated, Resident 9 had moderately impaired cognition (making poor decisions, cues and supervisions required). During a review of Resident 9's PASRR Level 1 screening dated 5/21/2025 indicated Resident 9 did not have any serious mental disorder diagnoses such as schizophrenia. The facility did not ensure PASRR level 1 accurately included Resident 9's medical diagnosis of paranoid schizophrenia. During a review of Resident 9's Care Plan (CP a guideline for nurses to help them create and achieve a solid plan of action in the treatment of a patient) did not include focus, goals, and interventions related to PASARR Level I and Level II (necessary to confirm the indicated diagnoses noted in the Level I screening, and to determine whether placement or continued stay in a nursing facility is appropriate) tailored to Resident 9's mental health needs. During a review of Resident 9's CP dated 6/15/2025, indicated, Resident 9 uses antidepressant medication related to diagnosis of depression. The CP has a goal of Resident 9 will be free from discomfort or adverse reactions relate to antidepressant therapy and that Resident 9 will show decreased episodes and signs and symptoms of depression. The CP interventions indicated to monitor/document/report any adverse reactions to antidepressant therapy. During a review of Resident 9's Psychiatry (Is the branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional and behavioral disorder) follow up note (a document that records a patient's mental health treatment, observations, and progress) dated 10/8/25, indicated Resident 9 had a history of depression. Resident 9 reported feeling depressed and hopeless due to current situation and health status. Resident 9 had trouble with memory recall. Resident 9 was on Sertraline for depression. During a review of Resident 9's physician's progress notes (a doctor's written record that documents a patient's health status, treatment, and care plan) dated 11/24/2025, indicated Resident 9 had diagnoses of unspecified dementia with behavioral disturbance, anxiety disorder and schizophrenia. Resident 9 was evaluated on an urgent basis due to symptoms or concerns that required immediate attention to avoid serious harm or a visit to the emergency room. Progress notes indicated Resident 9 was having memory loss and that Resident 9 lacks the capacity to make medical decisions. During a review of Resident 9's Medication Administration Record (MAR - a report detailing the drugs administered to a patient by a licensed healthcare professional at a facility) for 12/2025, indicated, Resident 9 was taking Sertraline (Zoloft - treats depression) daily at bedtime for depression. Residents Affected - Few 055711 Page 3 of 7 055711 12/04/2025 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review on 12/04/2025 at 2:12 PM with Director of Nursing (DON), Resident 9's medical diagnoses on the face sheet, care plans, and PASARR Level 1, Section III, number 9, were reviewed. DON stated Resident 9 had medical diagnoses of paranoid schizophrenia, unspecified dementia with mood disturbance and anxiety. DON stated the facility's admissions coordinator, who is not a licensed nurse, is responsible to check the PASARR Level 1 form for completeness but not for accuracy. DON stated the PASARR Level 1 form was not accurately completed, because [Resident 9] has schizophrenia and depression and that Resident 9 was taking Sertraline for depression. DON stated the facility had the responsibility to get a correct PASARR for Resident 9 if the one the facility received from the hospital was incorrect. DON added, It is our responsibility to correct the PASARR. Bottom line is we need to get a new PASARR for [Resident 9]. DON stated Resident 9 did not have a care plan related to PASARR Level 1 and/or Level II, because PASARR was not done correctly, the care plan will not show that. DON stated Resident 9 needed a care plan, because it is helpful for us to understand [Resident 9's] needs, what interventions we need to employ and what we need to maintain for good mental health. DON stated the potential harm for not accurately/correctly completing PASARR Level I form included not meeting/capturing Resident 9's needs in the care plan. When DON was asked how the facility determined if Resident 9 needed or did not need DON stated completing PASARR Level I screening accurately would determine if the resident qualified for a PASARR Level II screening. A review of the facility policy and procedures (P&P policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled PASARR Policy with revision date of 5/2024, indicated, The DON or the RN Supervisor completes the PASARR before admitting a resident on admission date. The facility will complete a PASARR timely according to the time frames required for all recipients initially entering a nursing facility. 055711 Page 4 of 7 055711 12/04/2025 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide reasonable accommodation resident preferences and choices for one out of 18 sampled residents (Resident 21). This deficient practice resulted in Resident 21 receiving bed baths instead of showers and had the potential to result in the Resident 21 inability to attain and maintain his/her highest practicable well-being with activities of daily living (ADLs). A review of Resident 21's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that include but are not limited to chronic obstructive pulmonary disease (COPD- progressive lung disease characterized by persistent and often worsening airflow limitation, which makes it hard to breathe), anemia (blood disorder in which the blood has a reduced ability to carry oxygen to the rest of the body), morbid obesity (significant amount of excess weight) abnormality of gait and mobility (deviation from a normal walking pattern, , coordination and, balance) and muscle weakness. A review of Resident 21's Minimum Data Set (MDS - a resident assessment tool, and care-screening tool) dated 9/2/2025, indicated the Resident 21's cognition was intact. A review of Resident 21's history and physical (H&P) dated 9/2/2025 indicated Resident 21 can make decisions for activities of daily living. During an interview on 12/2/2025, at 10:42am, Resident 21 stated she would like to take a shower, but she is only receiving bed baths because facility does not have a bariatric shower chair (a heavy-duty, extra-wide, and reinforced seat designed for individuals with larger body sizes, providing safe, stable support for bathing and hygiene by accommodating higher weight capacities (often 300-600+ lbs.), Resident 21 stated that she has not had a shower since admission to the facility During an interview on 10/2/2025, at 11:02 AM., Certified Nurse Assistant (CNA) 1 stated all Residents received showers twice a week on their scheduled days and needed. During an interview on 10/2/2025, at 11:10 AM, the Rehabilitation Services Director (RSD) and Director of Staff Development (DSD) stated staff (unidentified) was unable to provide a shower to Resident 21 because she (Resident 21) was unable to bear weight on her lower extremities and transferring Resident 21 back to bed after a shower is not safe for both the Resident and staff. Facility was observed to have a bariatric shower chair that could accommodate up to 500lbs (Resident 21 is 369 lbs.) and a functional Hoyer lift (a mechanical assistive device used by caregivers to safely transfer individuals with limited mobility from one surface to another (like bed to chair). A review of Resident 21's order summary dated 12/4/2025 indicated an order dated 12/3/2025 for bed bath only for safety. During an interview on 12/4/2025, at 2:20 PM., Director of Nursing (DON) stated facility has a bariatric shower chair that can support up to 500lbs, DON reiterated that the problems is safety concerns for Resident 21 who is unable to bear weight in legs, DON stated facility is seeking options to facilitate Resident 21's need for showers such as a bariatric shower bed, DON stated Resident's rights must be maintained to ensure Residents do not feel like a burden or not allowed to have things they should have access to and for Residents to feel comfortable in the facility A review of facility policy and procedures (P&P) titled showers and bathing policy undated, indicated, Residents are offered two (2) baths and showers per week, with additional bathing based on the resident's preference. Bathing assistance promotes independence, dignity, privacy and choice. Residents Affected - Few 055711 Page 5 of 7 055711 12/04/2025 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to consistently honor food preferences that had been requested for one (1) out of 18 sampled Resident (Resident 51)These deficient practices had the potential to result in weight loss due to inadequate calories in residents who did not receive the correct amount or food items of their choices of their preference.A review of Resident 51's admission record indicated the Resident was admitted to the facility on [DATE] with diagnoses that include but are not limited to Diverticulosis (small pouches or pockets in the inside walls of your intestines), liver transplant (surgery to replace a diseased liver with a healthy liver from another person), pulmonary fibrosis (scarring and thickening in your lungs that makes it hard to breathe deeply), chronic kidney disease (a long-term condition where kidneys are damaged and gradually lose their ability to filter waste and extra fluid from the blood), abnormalities of gait and mobility (deviation from a normal walking pattern, coordination and, balance) and depression (persistent sadness and loss of interest, affecting how you feel, think, and handle daily life). A review of Resident 51's Minimum Data Set (MDS - a resident assessment tool, and care-screening tool) dated 11/10/2025, indicated the resident 51's cognition was moderately impaired, Resident 51 required supervision or touching assistance with eating and oral hygiene and personal hygiene. A review of Resident 51's order summary dated 12/4/2025 indicated the Resident was on a vegetarian with no added salt diet of regular texture, and thin liquids for drinks, no food likes and/or dislikes were listed. During an initial facility tour on 12/1/2025 at 8:09 AM, Resident 51 stated as he was eating his breakfast, they (facility staff), gave me eggs, I don not eat eggs, every day they bring me eggs. Resident 51 stated he indicated to the Dietary Supervisor (DS) following his admission that he does not eat eggs. A review of Resident 51's breakfast Meal menu ticket dated 12/1/2025 indicated Resident 51 was on a vegetarian Diet of a regular texture with thin liquid consistency for drinks with, Omelet (Omelette) 1 SQ, listed as one of the items served for breakfast. During an interview with the Dietary Supervisor (DS) on 12/4/2025 at 11:34 AM, DS stated she usually visits the newly admitted Residents on the day of their admission, on the following day of Resident is admitted after business hours and/or on a Monday if the Resident is admitted over the weekend. DS stated she had visited Resident 51 following his admission on [DATE], DS stated Residents food dislikes and/or preferences are listed on the Residents meal tickets, DS was unable to state why Resident 51's dislike for eggs was not listed on his (Resident 51's) meal ticket. DS stated failing to honor a residents food preference could cause Resident to avoid eating their meals, leading to lose of weight and resulting in poor health outcomes. A review of facility policy and procedure (P&P) titled Food Procedure, Food Preparation dated 1/1/2018 indicated, The facility must provide each resident with a nourishing palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of reach resident. 055711 Page 6 of 7 055711 12/04/2025 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure dietary staff did not store foods in the kitchen beyond their expiration date and meat was not sitting in a dark reddish liquid. This deficient practice of storing food in the kitchen beyond their expiration date and meat sitting in a dark reddish liquid may cause all residents possible serious complications from foodborne illnesses (refer to illnesses such as nausea, vomiting, and diarrhea, caused by the ingestion of contaminated food or beverages). Findings: During a concurrent observation and interview on 12/01/2025 from 8:02 AM with the Dietary Services Supervisor (DSS - manages daily food service operations, ensuring safe, nutritious, and appealing meals while supervising staff, controlling budgets, and upholding health regulations), then following were identified:Grated parmesan cheese was found inside the refrigerator in its original plastic package open and stored inside a medium plastic bag with a handwritten open date of 11/16/2025 and an expiration date of 11/21/2025. A yellow and white pre-printed label with an expiration date of 1/16/2026 was placed on top of the handwritten expiration date covering the handwritten expiration date. DSS did not answer when asked why the pre-printed label was covering the handwritten expiration date. DSS stated, The cheese needs to be discarded because the handwritten expiration date has already expired. Smoked [NAME] cheese was found in the refrigerator in its original plastic package with a handwritten 11/14/2025 and an expiration date of 11/21/2025. The manufacturer's expiration date was not found on the plastic package. The yellow and white pre-printed label indicated American Cheese with an expiration date of 2/22/2026 was placed on top of the handwritten expiration date covering the handwritten expiration date. DSS again stated the cheese needs to be discarded because then handwritten expiration date has already expired. Five beef patties were found in the refrigerator in its original plastic package opened and stored inside a round plastic container with a handwritten open date of 11/30/2025 and a used by date of 12/02/2025. The five beef patties were observed to be soaking in a dark reddish liquid. DSS stated, The liquid is not normal to me. I will toss the meat now. When asked if the beef patties were safe to cook and serve to residents, DSS stated, No, because the meat is discolored. DSS stated the potential ham that may come to any of the residents was that they will have diarrhea, nausea, and vomiting. A review of the facility policy and procedures (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Labeling/Date Marking and Safe Storage of Refrigerated and Frozen Foods with a revision date of 10/2023, indicated, Commercially processed foods .must be dated.are good for seven days, or until the expiration date.on the label if [the date] comes before the 7th day. According to the P&P, the recommended storage time for ground meat/patties is 1 to 2 days from package opening. 055711 Page 7 of 7