Health inspection·November 22, 2024

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few feedings should be labeled with a date and time to ensure the feedings are changed timely and not administered past the correct duration and time. During an interview on 11/20/2024 with the Director of Nursing (DON), the DON stated that enteral feeding should be accurately labeled with a date and time prior to administrating to a resident. The DON further stated failing to accurately label the g-tube feeding with a date and time prior to administration could cause prolonged administration past duration deadline, which could lead to growth of pathogens that cause food borne illnesses such as stomach infection by consuming food that is past is use resulting in pathogen (germ) exposure resulting in unnecessary hospitalization and/or poor health outcomes. During a review of manufacturer ' s guidelines for the enteral feeding indicated, Use for a maximum of 48 hours after connection During a review of facility's policy and procedures titled Enteral Feedings-Safety Precaution dated, revised 11/2018 subtitled Preventing contamination indicated, maintain strict adherence to maximum hang times: Sterile formula in a closed system has a maximum hang time of 48 hours. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055748 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055748 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunset Park Healthcare 2250 29th Street Santa Monica, CA 90405 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 out of four residents received the correct therapeutic dose (of oxygen (a colorless, odorless gas that is essential for life and the proper functioning of the body) as ordered by the physician Residents Affected - Few This deficient practice placed Resident 4 at risk of oxygen poisoning (lung damage that happens from breathing in too much extra (supplemental) oxygen.) and had the potential to negatively impact the Resident 4 ' s health and well-being. Findings: During a review of Resident 4's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included, encephalopathy (a change in your brain function due to injury or disease), dysphagia (difficulty swallowing), depression (a depressed mood or loss of pleasure or interest in activities for long periods of time) and chronic obstructive pulmonary disease (COPD- lung disease marked by permanent damage to tissues in the lungs) During a review of Resident 4s Minimum Data Set (MDS - resident assessment tool) dated 9/17/2024, indicated Resident 4 had moderately impaired cognition. The MDS also indicated Resident 4 required set-up and clean-up assistance with eating, partial moderate assistance with oral hygiene, upper body dressing, and personal hygiene and, was totally dependent for toileting hygiene, shower/bathing, lower body dressing and putting on footwear. Resident 4 was totally dependent for bed mobility sit to lying on side of the bed. The MDS also indicated the resident was non-ambulatory. During a review of Resident 4's Order Summary Report dated 11/20/2024 indicated physician's order for oxygen at two (2) liters per minute via nasal cannula continuously to keep oxygen saturation equal or greater than 94% for shortness of breath every shift for Residentt 4. During the initial tour on 11/20/2024 at 10:45am, Resident 4 was observed asleep in bed, an oxygen concentrator machine (a medical device that concentrates oxygen from environmental air and delivers it to the resident in need of supplemental oxygen) was observed at bedside flowing at 5 liters (unit measure) per minute (duration) -l/min) flowing via the Resident ' s nasal cannula (a device used to deliver supplemental oxygen that should be placed directly on the resident's nostrils) Resident 4 ' s was observed resting comfortably in bed with no distress and unlabored breathing. During an observation and a concurrent interview on 11/20/2024 at 10:55 am Licensed Vocational Nurse 1 (LVN 1), stated Resident 4 has an order for continuous oxygen at 2L/min, a nasal cannula for shortness of breath (SOB), LVN 1 was unable to answer when asked why Resident 4 was receiving 5 L/min instead of the physician ' s order of 2L/min. During an interview on 11/20/2024 at 1:41 P.M., the Director of Nursing (DON) stated Resident 4 was at risk for oxygen overdose can cause the lungs to expand more and affect breathing due to over oxygenation which can cause the Resident to stop breathing and die. During a review of the facility's policy and procedures titled, Oxygen Administration, dated 10/2010 indicated the purpose of this procedure is to provide safe oxygen administration. Policy states, Verify that physicians order for oxygen and facility protocol for oxygen administration .unless (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055748 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055748 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunset Park Healthcare 2250 29th Street Santa Monica, CA 90405 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 otherwise ordered, start the flow of oxygen at the rate of 2 to 3 l/min. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055748 If continuation sheet Page 4 of 4