Health inspection·February 28, 2025

F 0624 Prepare residents for a safe transfer or discharge from the nursing home. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review for one of three sampled residents, Resident 1. The facility failed to provide and review discharge care instructions with the resident representative (RR) at the time of discharge. Residents Affected - Few This deficient practice caused the RR to be unsure of the follow up instructions for Resident 1 ' s stage II pressure ulcer (Partial-thickness loss of skin, presenting as a shallow open sore or wound) on the sacrum (lower back) after discharge. Findings: During a record review, Resident 1 ' s admission Record indicated the facility originally admitted Resident 1 on 12/3/2024 and most recently on 1/7/2025 with diagnoses including, central cord syndrome at the cervical spine (injury of the spinal cord causing weakness in arms and legs), fracture of the second vertebrae (broken neck), Alzheimer ' s disease (a disease characterized by a progressive decline in mental abilities), essential hypertension (high blood pressure), end stage renal disease (End Stage Renal Disease-irreversible kidney failure) with attention to dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in mental abilities), hyperlipidemia (high fat in the blood), gout (arthritis in the joint) and stage II pressure injury on the sacrum. During a record review, Resident 1 ' s Physician Order dated 1/8/2025 indicated Santyl (medication used to remove dead skin from wounds) ointment 250 units/gm apply to sacrum topically every day shift for stage II pressure injury on sacrum. During a record review, Resident 1 ' s Minimum Data Set (MDS-a resident assessment) dated 1/13/2025 indicated Resident 1 ' s cognition (mental ability to make decisions for daily living) was not intact. The MDS indicated Resident 1 was dependent (helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) with toileting, personal hygiene, and transfers (moving between surfaces) from bed to chair. The MDS also indicated Resident 1 had one unhealed pressure ulcer. During a record review, Resident 1 ' s physician order dated 1/17/2025 indicated discharge order: last covered day for skilled service on 1/16/2025 may discharge with home health and physical therapy on 1/17/2025. On 2/26/2025 The California Department of Public Health (CDPH) received a complaint alleging the facility discharged Resident 1 to dialysis on 1/17/2025 and failed to send discharge instructions with Page 1 of 2 056334 056334 02/28/2025 Beachwood Post-Acute & Rehab 1340 15th Street Santa Monica, CA 90404

F 0624 resident or provide any discharge instructions for wound care. Level of Harm - Minimal harm or potential for actual harm During an interview on 2/27/2025 at 3:40 p.m. the RR stated, I was told he would be sent home with the discharge instructions however on Friday, 1/17/2025 [Resident 1] came home via ambulance from dialysis at about 5 p.m. with no discharge instructions. My niece had to go to the facility on Sunday 1/19/2025 and get the instructions. We did not know what to do for the wound because there were no instructions. During a concurrent interview and record review on 2/28/2025 at 11:55 a.m. with the Registered Nurse (RN), Resident 1 ' s nursing progress note dated 1/19/2025 indicated resident 1 went to dialysis on 1/17/2025 and discharged home from dialysis. Note further indicated 1/19 timed 5:30 p.m. the niece of Resident 1 came to collect Resident 1 ' s belongings and inquired about the discharge documents. The nursing progress note indicated the niece collected the discharge documents and was educated on discharge summary, verbalized understanding, signed documents and left facility. The RN stated, I was not aware resident 1 was to be discharged home after dialysis until resident 1 had already left for dialysis. The RN stated, It is typically the charge nurse that would review the discharge instructions including the medications and any follow up appointments with the resident and or family at the time of discharge. The RN stated, I did not send resident 1 to dialysis so I am not sure what happened. Residents Affected - Few During an interview on 2/28/2025 at 12:48 p.m. with the Case Manager (CM), the CM stated, All residents discharge instructions are placed in a blue folder and contains their specific appointments and medications as well as generic information on different available resources. I usually go over the resources and the RN will review the medications and future appointments. On 1/17/2025 I came to the floor and put the blue folder in Resident 1 ' s bag when [Resident 1] left for dialysis and informed the [RR] the folder would be in [Resident 1 ' s] bag. I am not sure if the RN reviewed the medications, appointments or wound care information. I did not speak to the [RR] regarding any wound care instructions. During a record review, the facility policy and procedures titled, Discharging the Resident revised 1/2024 indicated, If the resident is being discharged home. Ensure that resident and/or responsible party will have discharge instructions. 056334 Page 2 of 2