Health inspection·May 7, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its policy and procedures titled Requesting, Refusing and/or Discontinuing Care and Treatment, reviewed March 2025, for one of three sampled residents (Resident 1). By failing to notify Resident 1 ' s physician of the resident ' s refusal to take prescribed tuberculosis (TB, a contagious disease caused by the bacteria Mycobacterium tuberculosis, which typically affects the lungs) medications: 1. Isoniazid (used to treat TB and/or prevent its return) 300 milligrams (mg, metric unit of measure) refused on 4/9/25, 4/12/25, 4/13/25, 4/25/25, and 5/2/25. 2. Pyridoxine 50 mg (treats vitamin B6 deficiency) refused on 4/9/25, 4/12/25, 4/13/25, 4/25/25, and 5/2/25. 3. Rifampin (antimicrobial medication used to kill TB bacteria in the body) 300 mg refused on 4/20/25, 4/25/25, and 5/2/25. This deficient practice had the potential to result in Resident 1 becoming reinfected with active TB, a delay in care and treatment, or cause a decline on overall medical condition resulting in death. Findings: During a review of Resident 1's admission Record dated 5/7/25, the admission record indicated, the resident was admitted to the facility on [DATE] with diagnoses including anemia (a condition where the body does not have enough healthy red blood cells), TB, hypertension (high blood pressure), and abnormalities of gait (balance) and mobility. During a review of Resident 1 ' s Minimum Data Set (MDS—a resident assessment tool) dated 3/23/25, the MDS indicated, Resident 1 had severe cognitive (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) impairment, and required partial/moderate assistance (helper does less than half of the effort) for eating, oral hygiene, toileting, showering/bathing, and dressing and required supervision or touching assistance for bed mobility and transfers. During a review of Resident 1 ' s Oder Summary Report dated 5/7/25, the report indicated an order for isoniazid oral tablet 300 mg by mouth one time a day for TB until 8/12/25, pyridoxine hydrochloride oral tablet 50 mg give 1 tab by mouth one time a day for supplement until 8/12/25, and rifampin (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 05/07/2025 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)