Health inspection·January 10, 2024

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a copy of the Notice of Proposed Transfer or Discharge (NPTD) Form for facility-initiated transfer (the resident expects to return to the facility) or discharge (when return to the facility is not expected) was sent to a representative of the Office of the State Long-Term Care (LTC) Ombudsman Program (advocates for residents in nursing homes) before transfer, discharge or in emergency situations as soon as practicable for 14 of 23 sampled residents (Residents 5, 6, 7, 8, 9, 10, 11, 12, 13, 16, 17, 18, 22, and 24). As a result, Residents 5, 6, 7, 8, 9, 10, 11, 12, 13, 16, 17, 18, 22, and 24 were denied protection and advocacy in the event residents were inappropriately or involuntary transferred or discharged from the facility. Findings: 1. A review of Resident 5 ' s admission Record indicated the facility originally admitted the resident on 12/4/2022 and re-admitted Resident 5 on 12/28/2022. A review of Resident 5 ' s Physician ' s Order dated 1/10/2023, indicated Resident 5 had an order to be discharged home on 1/13/2023 with Home Health (HH - health care services provided at home) services. A review of Resident 5 ' s NPTD Form with a notification date of 1/11/2023 indicated the discharge was appropriate because Resident 5's health improved sufficiently and no longer required services provided by the facility. A review of the facility ' s fax verification form indicated that the facility faxed a copy of Resident 5 ' s NPTD Form to the LTC Ombudsman on 4/24/2023. 2. A review of Resident 6 ' s admission Record indicated the facility admitted Resident 6 on 2/3/2023. A review of Resident 6 ' s Physician Order dated 2/6/2023 indicated Resident 6 had an order to be discharged home on 2/6/2023 with HH services. A review of Resident 6 ' s NPTD Form with a notification date of 2/12/2023 indicated the discharge was appropriate because Resident 6's health improved sufficiently and no longer required services provided by the facility. Page 1 of 7 056253 056253 01/10/2024 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of the facility ' s NPTD Form binder, there were no fax verifications found indicating a copy of Resident 6 ' s NPTD Form was faxed to the LTC Ombudsman. 3. A review of Resident 7 ' s admission Record indicated the facility admitted the Resident 7 on 2/9/2023. A review of Resident 7 ' s Physician Order dated 2/15/2023 indicated Resident 7 had an order to be discharged to a Board and Care Home (BC Home - houses in residential neighborhoods that are equipped and staffed to care for a small number of residents) on 2/18/2023 with HH services. A review of Resident 7 ' s NPTD Form with a notification date of 2/18/2023 indicated the discharge was appropriate because Resident 7's health improved sufficiently and no longer required services provided by the facility. During a review of the facility ' s NPTD Form binder, there were no fax verifications found indicating a copy of Resident 7 ' s NPTD Form was faxed to the LTC Ombudsman. 4. A review of Resident 8 ' s admission Record indicated the facility admitted Resident 8 on 2/28/2023. A review of Resident 8 ' s Physician ' s Order dated 3/6/2023, indicated Resident 8 had an order to be discharged home on 3/6/2023 with HH services. A review of Resident 8 ' s NPTD Form with a notification date of 3/6/2023 indicated the discharge was appropriate because Resident 8's health improved sufficiently and no longer required services provided by the facility. A review of the facility ' s fax verification form indicated that the facility faxed a copy of Resident 8 ' s NPTD Form to the LTC Ombudsman on 5/24/2023. 5. A review of Resident 9 ' s admission Record indicated the facility admitted Resident 9 on 1/5/2023. A review of Resident 9 ' s Physician ' s Order dated 3/6/2023, indicated Resident 9 had an order to be discharged home on 3/9/2023 with HH services. A review of Resident 9 ' s NPTD Form with a notification date of 3/9/2023 indicated the discharge was appropriate because Resident 9's health improved sufficiently and no longer required services provided by the facility. A review of the facility ' s fax verification form indicated that the facility faxed a copy of Resident 8 ' s NPTD Form to the LTC Ombudsman on 5/24/2023. 6. A review of Resident 10 ' s admission Record indicated the facility admitted Resident 10 on 2/6/2023. A review of Resident 10 ' s Physician ' s Order dated 4/11/2023, indicated Resident 10 had an order to be discharged home on 4/11/2023 with HH services. 056253 Page 2 of 7 056253 01/10/2024 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 10 ' s NPTD Form with a notification date of 4/11/2023 indicated the discharge was appropriate because Resident 10's health improved sufficiently and no longer required services provided by the facility. A review of the facility ' s fax verification form indicated that the facility faxed a copy of Resident 10 ' s NPTD Form to the LTC Ombudsman on 7/5/2023. 7. A review of Resident 11 ' s admission Record indicated the facility admitted Resident 11 on 4/9/2023. A review of Resident 11 ' s Physician ' s Order dated 4/17/2023, indicated Resident 11 had an order to be discharged home on 4/20/2023 with HH services. A review of Resident 11 ' s NPTD Form with a notification date of 4/20/2023 indicated the discharge was appropriate because Resident 11's health improved sufficiently and no longer required services provided by the facility. A review of the facility ' s fax verification form indicated that the facility faxed a copy of Resident 11 ' s NPTD Form to the LTC Ombudsman on 7/5/2023. 8. A review of Resident 12 ' s admission Record indicated the facility admitted Resident 12 on 5/8/2023. A review of Resident 12 ' s Physician ' s Order dated 5/9/2023, indicated Resident 12 had an order to be discharged home on 5/14/2023 with HH services. A review of Resident 12 ' s NPTD Form with a notification date of 5/14/2023 indicated the discharge was appropriate because Resident 12's health improved sufficiently and no longer required services provided by the facility. A review of the facility ' s fax verification form indicated that the facility faxed a copy of Resident 12 ' s NPTD Form to the LTC Ombudsman on 10/13/2023. 9. A review of Resident 13 ' s admission Record indicated the facility admitted Resident 13 on 4/20/2023. A review of Resident 13 ' s Physician ' s Order dated 5/16/2023, indicated Resident 13 had an order to be discharged to an Assisted Living Facility (ALF - a residence for older people or people with disabilities who require help with some of the routines of daily living as well as access to medical care when needed) on 5/17/2023 with HH services. A review of Resident 13 ' s NPTD Form with a notification date of 5/17/2023 indicated the discharge was appropriate because Resident 13's health improved sufficiently and no longer required services provided by the facility. A review of the facility ' s fax verification form indicated that the facility faxed a copy of Resident 13 ' s NPTD Form to the LTC Ombudsman on 10/13/2023. 10. A review of Resident 16 ' s admission Record indicated the facility originally admitted 056253 Page 3 of 7 056253 01/10/2024 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

F 0623 Resident 16 on 2/4/2023 and re-admitted Resident 16 on 6/23/2023. Level of Harm - Minimal harm or potential for actual harm A review of Resident 16 ' s Physician ' s Order dated 7/3/2023, indicated Resident 16 had an order to be discharged home on 7/7/2023 with HH services. Residents Affected - Some A review of Resident 16 ' s NPTD Form with a notification date of 7/7/2023 indicated the discharge was appropriate because Resident 16's health improved sufficiently and no longer required services provided by the facility. A review of the facility ' s fax verification form indicated that the facility faxed a copy of Resident 16 ' s NPTD Form to the LTC Ombudsman on 10/19/2023. 11. A review of Resident 17 ' s admission Record indicated the facility admitted Resident 17 on 6/22/2023. A review of Resident 17 ' s Physician ' s Order dated 7/3/2023, indicated Resident 17 had an order to be discharged home on 7/7/2023 with HH services. A review of Resident 17 ' s NPTD Form with a notification date of 7/7/2023 indicated the discharge was appropriate because Resident 17's health improved sufficiently and no longer required services provided by the facility. A review of the facility ' s fax verification form indicated that the facility faxed a copy of Resident 17 ' s NPTD Form to the LTC Ombudsman on 10/19/2023. 12. A review of Resident 18 ' s admission Record indicated the facility admitted Resident 18 on 7/25/2023. A review of Resident 18 ' s Physician ' s Order dated 8/3/2023, indicated Resident 18 had an order to be discharged home on 8/8/2023 with HH services. A review of Resident 18 ' s NPTD Form with a notification date of 8/8/2023 indicated the discharge was appropriate because Resident 18's health improved sufficiently and no longer required services provided by the facility. A review of the facility ' s fax verification form indicated that the facility faxed a copy of Resident 18 ' s NPTD Form to the LTC Ombudsman on 10/20/2023. 13. A review of Resident 22 ' s admission Record indicated the facility admitted Resident 22 on 10/1/2023. A review of Resident 22 ' s Physician ' s Order dated 10/5/2023, indicated Resident 22 had an order to be discharged home on [DATE] with HH services. A review of Resident 22 ' s NPTD Form with a notification date of 10/6/2023 indicated the discharge was appropriate because Resident 22's health improved sufficiently and no longer required services provided by the facility. A review of the facility ' s fax verification form indicated that the facility faxed a copy of 056253 Page 4 of 7 056253 01/10/2024 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

F 0623 Resident 22 ' s NPTD Form to the LTC Ombudsman on 12/19/2023. Level of Harm - Minimal harm or potential for actual harm 14. A review of Resident 24 ' s admission Record indicated the facility admitted Resident 24 on 11/18/2023. Residents Affected - Some A review of Resident 24 ' s Physician ' s Order dated 11/27/2023, indicated Resident 24 had an order to be discharged home on [DATE] with HH services. A review of Resident 24 ' s NPTD Form with a notification date of 11/29/2023 indicated the discharge was appropriate because Resident 24's health improved sufficiently and no longer required services provided by the facility. A review of the facility ' s fax verification form indicated that the facility faxed a copy of Resident 24 ' s NPTD Form to the LTC Ombudsman on 12/19/2023. During an interview on 12/18/2023 at 3:00 p.m., with the Social Services 1 (SS 1), when SS 1 was asked how soon the facility notifies the LTC Ombudsman of a facility-initiated transfer or discharge, SS 1 stated she received instructions from the former Social Services Director (SSD) that the facility needed to fax a copy of the residents ' NPTD on a monthly basis for all transfers or discharges to the LTC Ombudsman. During a concurrent interview and record review on 12/22/2023 at 11:16 a.m. with SS 1, SS 1 reviewed the facility ' s NPTD binder and stated the fax verifications indicated copies of residents ' NPTD for the year of 2023 were faxed to LTC Ombudsman as follows: 1. Residents ' NPTD for January 2023 were faxed on 4/24/2023 2. Residents ' NPTD for February 2023: No fax verifications were found. 3. Residents ' NPTD for March 2023 were faxed on 5/24/2023 4. Residents ' NPTD for April 2023 were faxed on 7/5/2023 5. Residents ' NPTD for May 2023 were faxed on 10/13/2023 6. Residents ' NPTD for June 2023 were faxed on 10/17/2023 7. Residents ' NPTD for July 2023 were faxed on 10/19/2023 8. Residents ' NPTD for August 2023 were faxed 10/20/2023 9. Residents ' NPTD September 2023, October 2023, November 2023, and December 2023 were faxed on 12/19/2023. During an interview with the Director of Nursing (DON) on 12/22/2023 at 1:52 p.m., the DON stated, as soon as a last coverage date was decided, the facility issues the NPTD to the residents or responsible parties notifying them of ending skilled insurance benefits. The DON stated these cases fall under the category of facility-initiated discharges and the facility should have notified the LTC Ombudsman as soon as practicable. 056253 Page 5 of 7 056253 01/10/2024 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the facility ' s P&P titled, Transfer or Discharge Notice, dated June 2020, last reviewed on 5/18/2022, indicated, A resident and/or his or her representative (sponsor) will be given a 30-day notice of an impending transfer or discharge from our facility. Under the following circumstances, the notice will be given as soon as it is practicable of the transfer or discharge The transfer of discharge is appropriate because the resident ' s health has improved sufficiently so the resident no longer needs the services provided by the facility A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman. 056253 Page 6 of 7 056253 01/10/2024 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1) had a physician ' s order to administer supplemental oxygen (O2- a treatment that provides you with extra oxygen to breathe in) prior to providing the resident with oxygen. Residents Affected - Some This deficient practice had the potential to result in complications from lack of sufficient oxygen level in the body and lead to shortness of breath (SOB), rapid breathing, confusion, and loss of consciousness and irregular heartbeats. Findings: A review of Resident 1 's admission Record indicated the facility admitted the resident on 2/13/2020 and readmitted the resident on 6/25/2020 with diagnosis including cerebral infarction (damage to tissues in the brain due to a loss of oxygen) and hypoxia (low levels of oxygen in your body tissues). A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 11/11/2023, indicated the resident is able to understand others and is understood by others. The MDS further indicated that Resident 1 needed moderate assistance for oral and personal hygiene. A review of Resident 1 ' s physician order summary dated 7/1/2023 to 10/1/2023 indicated that there were no orders for Resident 1 to receive supplemental oxygen. A review of Resident 1 ' s Records of O2 sat from 7/1/2023 through 10/1/2023 indicated that Resident 1 received supplemental oxygen via nasal cannula (NC - a medical device that delivers extra oxygen through a tube and into the nose) on the following days: 1. In July/2023: 1, 2, 3, 4, 5, 7, 10, 14, 18, 19, 22, 24, 26, 28, 29, and 31. 2. In August/2023: 2, 4, 8, 9, 14, 16, 20, 21, 25, and 27. 3. In September/2023: 2. 4. In October/2023: 1. During a concurrent interview and record review on 12/18/2023 at 1:45 p.m. with the Director of Nursing (DON), Resident 1 ' s physician orders from 7/1/2023 to 10/1/2023 was reviewed. DON stated that there were no active physician orders for Resident 1 to receive supplemental O2 from 7/1/2023 to 10/1/2023. DON stated that from 7/1/2023 to 10/1/2023, Resident 1 received supplemental oxygen without a physician ' s order. A review of the facility ' s policy and procedures dated 05/2020 and reviewed 5/18/2022, titled Oxygen Administration, indicated, To administer oxygen for the treatment of disease or a condition. 056253 Page 7 of 7