Health inspection·June 17, 2025

F 0563 Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. 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 permit residents to receive visitors according to the facility ' s policy and procedures (P&P) titled, Visitation and Resident Rights, for one of four sampled residents, Resident 1. Residents Affected - Few This deficient practice violated residents ' rights regarding visitation. Cross Reference F656. Findings: During a review of the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including respiratory tuberculosis (a contagious bacterial infection that involves the lungs), pneumonia (lung infection that inflames air sacs with fluid or pus) and depression (a mood disorder that causes persistent feeling of sadness and loss of interest). During a review of the Minimum Data Set (MDS – resident assessment tool) dated 3/23/2025, indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 required moderate assistance from 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 same MDS also indicated, Resident 1 experienced feeling down, depressed, or hopeless, and have little interest or pleasure in doing things in 2-6 days (several days) a week. During a review of Resident 1 ' s Interdisciplinary Team (IDT - a group of dedicated healthcare professionals who work to bring knowledge together to help residents receive the care they need) Notes, dated 3/12/2025, the IDT notes indicated, Resident 1 ' s Family Member 2 (FM 2) and Family Member 3 (FM 3) are not allowed to visit unless they are accompanied by Resident ' s Family Member 1 (FM 1). During a review of Resident 1 ' s Progress Notes dated 3/13/2025, the Progress Notes indicated, the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) notified the facility that according to the regulation, the facility cannot restrict visitation and Resident 1 ' s FM 1 cannot [NAME] visitors if Resident 1 would like to have them . FM 1 can restrict visitors only if the visitor put Resident 1 in immediate risk of threat or neglect. During a review of Resident 1 ' s Progress Notes dated 6/3/2025, the Progress Notes indicated, Two Page 1 of 4 055748 055748 06/17/2025 Sunset Park Healthcare 2250 29th Street Santa Monica, CA 90405

F 0563 Level of Harm - Minimal harm or potential for actual harm female visitors came (in the facility) and were attempting to walk down the hallway . FM 1 was called by the staff and FM 1 stated, he doesn ' t want them (two female visitors) to visit Resident 1 without him present. During a review of Resident 1 ' s Care Plan (CP), as of 6/17/2025, there was no CP developed regarding visitation and the IDT notes on 3/12/2025 regarding restricting FM 2 and FM 3 from visiting Resident 1. Residents Affected - Few During an interview with Social Services Director (SSD) on 6/17/2025 at 12:35 p.m., SSD stated, the facility cannot restrict visitation. SSD stated, there is some conflict and family dynamic between Resident 1 ' s FM 1 and FM 2. SSD reviewed Resident 1 ' s IDT notes dated 3/12/2025, and stated and confirmed, facility failed to follow P&P and regulations regarding residents ' rights. SSD stated, there is no care plan developed regarding the conflict between Resident 1 ' s FM 1 and FM 2. During an interview with Registered Nurse 1 (RN 1) on 6/17/2025 at 12:58 p.m., RN 1 stated, there was no neglect or harm done to Resident 1 from Resident 1 ' s FM 2 and FM 3. During a review of the facility ' s P&P titled, Resident Rights, revised on 3/2025, the P&P indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' s right to: . visit and be visited by others from outside the facility. During a review of the facility ' s P&P titled, Visitation, revised on 3/2025, the P&P indicated, Our facility permits residents to receive visitors subject to the resident ' s wishes and the protection of the rights of other residents in the facility . The facility does not restrict visitors based on the request of family members or the healthcare power of attorney (a legal document that allows an individual to empower another to make decisions about their medical care). 055748 Page 2 of 4 055748 06/17/2025 Sunset Park Healthcare 2250 29th Street Santa Monica, CA 90405

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 develop a comprehensive care plan (CP) that met the care/services based on the resident's individual assessed needs for one of six sampled residents (Resident 1), regarding visitation rights and conflicts between Resident 1 ' s Family Member 1 and Resident 1 ' s Family Member 2 (FM 2). This deficient practice had the potential to result negative impact on residents ' health and safety, as well as the quality of care and services received. Findings: During a review of the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including respiratory tuberculosis (a contagious bacterial infection that involves the lungs), pneumonia (lung infection that inflames air sacs with fluid or pus) and depression (a mood disorder that causes persistent feeling of sadness and loss of interest). During a review of the Minimum Data Set (MDS – resident assessment tool) dated 3/23/2025, indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 required moderate assistance from 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 same MDS also indicated, Resident 1 experienced feeling down, depressed, or hopeless, and have little interest or pleasure in doing things in 2-6 days (several days) a week. During a review of Resident 1 ' s Interdisciplinary Team (IDT - a group of dedicated healthcare professionals who work to bring knowledge together to help residents receive the care they need) Notes, dated 3/12/2025, the IDT notes indicated, Resident 1 ' s Family Member 2 (FM 2) and Family Member 3 (FM 3) are not allowed to visit unless they are accompanied by Resident ' s Family Member 1 (FM 1). During a review of Resident 1 ' s Progress Notes dated 3/13/2025, the Progress Notes indicated, the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) notified the facility that according to the regulation, the facility cannot restrict visitation and Resident 1 ' s FM 1 cannot [NAME] visitors if Resident 1 would like to have them . FM 1 can restrict visitors only if the visitor put Resident 1 in immediate risk of threat or neglect. During a review of Resident 1 ' s Progress Notes dated 6/3/2025, the Progress Notes indicated, Two female visitors came (in the facility) and were attempting to walk down the hallway . FM 1 was called by the staff and FM 1 stated, he doesn ' t want them (two female visitors) to visit Resident 1 without him present. During a review of Resident 1 ' s Care Plan (CP), as of 6/17/2025, there was no CP developed regarding visitation and the IDT notes on 3/12/2025 regarding restricting FM 2 and FM 3 from visiting Resident 1. During an interview with Social Services Director (SSD) on 6/17/2025 at 12:35 p.m., SSD stated, the 055748 Page 3 of 4 055748 06/17/2025 Sunset Park Healthcare 2250 29th Street Santa Monica, CA 90405

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility cannot restrict visitation. SSD stated, there is some conflict and family dynamic between Resident 1 ' s FM 1 and FM 2. SSD reviewed Resident 1 ' s IDT notes dated 3/12/2025, and stated and confirmed, facility failed to follow P&P and regulations regarding residents ' rights. SSD stated, there is no care plan developed regarding the conflict between Resident 1 ' s FM 1 and FM 2. During an interview with Registered Nurse 1 (RN 1) on 6/17/2025 at 12:58 p.m., RN 1 stated, there was no neglect or harm done to Resident 1 from Resident 1 ' s FM 2 and FM 3. RN 1 stated, there should be a CP developed regarding Resident 1 ' s visitation rights and the conflict between Resident 1 ' s FM 1 and FM 2. During a review of the facility ' s policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised on 3/2025, the P&P indicated, A comprehensive person-centered care plan that includes measurable objectives and timetables to meet resident ' s physical, psychological and functional needs is developed and implemented for each resident. 055748 Page 4 of 4