F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview, the facility failed to follow their own Policy and Procedure (P&P) by failing to
ensure one of three sampled residents (Resident 1), physician had educated Resident 1 or her
Responsible Party (RP) about the risks and benefits of taking mirtazapine (an antidepressant used to treat
major depressive disorder).
This deficient practice had the potential to result in Resident 1 in receiving a medication that she (Resident
1) was not well informed about.
Findings:
During a review of the admission record for Resident 1 indicated Resident 1 was initially admitted to the
facility on [DATE] and was readmitted on [DATE] with major depressive disorder (a mood disorder that
causes a persistent feeling of sadness and loss of interest), hypertension (HTN-high blood pressure) , and
dysphagia (difficulty swallowing).
During a review of the facility document titled INFORMED CONSENT- INFORMED CONSENT FOR USE
OF PSYCHOTROPIC MEDICATION, for Resident 1 indicated, mirtazapine 7.5 milligram (mg, unit of
measurement) PO (by mouth) qhs (at bedtime), an antidepressant used to treat depression. The same
informed consent indicated Resident 1 ' s RP was provided information on 2/23/2025, the name of the
physician with no physician signature, and the name and signature of staff who was the witness with no
date indicating when they witnessed the education provided.
During a review of Resident 1 ' s physician order dated 2/23/2025, indicated, mirtazapine 7.5 mg tablets
(tabs), give 1-tab po at bedtime for depression m/b (manifested by) poor po intake behavior.
During a review of the Minimum Data Set (MDS – a resident assessment tool) dated 3/4/2025,
indicated Resident 1 had severe cognitive impairment (a significant decline in thinking, learning,
remembering, and reasoning abilities, impacting daily functioning and potentially leading to the inability to
live independently). The same MDS indicated, Resident 1 required between partial/moderate assistance
and dependence on staff for most Activities of Daily Living such as: (ADLs- routine tasks/activities such as
eating, oral hygiene, toileting hygiene, personal hygiene, lower/upper body dressing, putting on/taking off
footwear).
During a concurrent interview and record review of Resident 1 ' s informed consent for mirtazapine with
Licensed Vocational Nurse (LVN) 1 on 4/15/2025 at 1:39 pm stated that for a consent to be
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
055748
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
04/15/2025
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 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
complete and accurate, education is provided and residents sign to indicate that they understand. She
stated that residents who have capacity to understand and make decisions give consent and RPs are
identified for residents who do not have capacity. LVN 1 stated that the physician needs to sign consents to
indicate that they had provided education, with risks and benefits to the resident. LVN 1 stated that if
signatures are not there, then the consents are not complete and therefore not valid. LVN 1 confirmed that
Resident 1 ' s consent for mirtazapine did not have a physician ' s signature and did not indicate a date of
when the facility staff witnessed the physician provide education to Resident 1.
During a concurrent interview and record review of Resident 1 ' s informed consent for mirtazapine with
Social Services Director (SSD) on 4/15/2025 at 2:04 pm, the SSD acknowledged that Resident 1 did not
include a physician signature and the date on when the facility staff witnessed the education regarding the
mirtazapine educating about the risks and benefits. The SSD stated that it was very important to get a
complete consent because antidepressants have a lot of side effects so residents must be well educated
about the medication before the medication are administered.
During a concurrent interview and record review of Resident 1 ' s informed consent for mirtazapine with
Director of Nursing (DON) on 4/15/2025 at 2:23 pm, the DON stated that that the physician must sign an
informed consent at least within 72 hours if that consent was obtained over the phone and immediately if
obtained in person. If a physician does not sign, then the consent is not effective. The DON confirmed that
Resident 1 ' s consent was not signed by the physician nor was it dated by the witness.
During a review of the facility P&P titled Verification of Informed Consent for Psychotherapeutic
Medications, revised 5/2024 indicated, Each resident has the right t be free from psychotherapeutic drugs
and, to provide informed consent before treatment with psychotherapeutic drugs. Informational materials
concerning psychotherapeutic drugs. The facility will obtain a written informed consent for treatment using
psychotherapeutic drugs and consent renewal every six months. the same P&P indicated, the if a
resident/RP cannot sign the consent, then a licensed nurse can sign, indicated the name of the person
giving consent along with a date. The physician signature may be signed using remote technology.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055748
If continuation sheet
Page 2 of 2
