Health inspection·April 1, 2025

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a notice of bed-hold policy and return form when the resident was transferred to General Acute Care Hospital 1 (GACH 1) for one of two sampled residents (Resident 1). This deficient practice had a potential to result in the resident's responsible party being unaware of the bed hold policy and can lead to a transfer of the resident to another skilled nursing facility not of the resident's or responsible party's preference. Findings: During a review of the Resident 1 ' s admission Record, it indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), ESRD (End Stage Renal Disease-irreversible kidney failure) and heart failure (a condition in which the heart does not pump blood as well as it should). The admission Record indicated, Resident 1 was discharged on 2/28/2025. During a review of the Minimum Data Set (MDS - resident assessment tool) dated 2/20/2025, indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 required maximal assistance to total dependent 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). During a review of Resident 1 ' s History and Physical (H&P) dated 2/21/2025, the H&P indicated, Resident 1 has the capacity to understand and make decisions. During a review of Resident 1 ' s SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 2/27/2025, the SBAR indicated the physician ' s recommendation to send Resident 1 to GACH 1 due to nausea and vomiting of coffee ground emesis (the forceful ejection of some or all of the contents of the stomach through the mouth). During a review of Resident 1 ' s Physician Order Summary and electronic and paper medical chart as of 4/1/2025, it indicated that there was no order for Bed-hold and no Bed-hold notice completed after Resident 1 was hospitalized on [DATE]. During an interview with the Assistant Director of Nursing (ADON) on 4/1/2025 at 2:11 p.m., ADON Page 1 of 6 056334 056334 04/01/2025 Beachwood Post-Acute & Rehab 1340 15th Street Santa Monica, CA 90404

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated, there was no physician order for Resident 1 ' s bed hold and there was no Bed hold notice completed after Resident 1 ' s hospitalization. ADON stated, he was unsure of the facility ' s policy and procedure (P&P) on bed hold but there should be a notification of Bed-hold and documentation if bed-hold was offered to Resident 1 and/or Resident 1 ' s responsible party. During an interview with Administrator (ADM) on 4/1/2025 at 3:29 p.m., Resident 1 did not have a Medi-cal (California's Medicaid program) insurance, and they don ' t put residents on bed hold if they don ' t have Medi-cal insurance. ADM stated, bed-hold notice, and bed hold information was not offered to Resident 1. During a review of the facility ' s policy and procedure (P&P) titled, Bed Hold (Medi-Cal), revised on 1/2025, the P&P indicated, If the patient must be transferred to an acute hospital for seven days or less, our team will notify the patient or their representative that we are willing to hold the patient's bed. The patient or their representative have 24 hours after receiving this notice to let us know whether they want us to hold the bed for the patient . The benefit of the bed hold is that during the bed hold period, it provides the patient with an opportunity to return to their bed in the same facility after their hospital stay . Individuals who do not have Medi-Cal have the option to pay to hold the bed until the patient can return. Based on interview and record review, the facility failed to complete a notice of bed-hold policy and return form when the resident was transferred to General Acute Care Hospital 1 (GACH 1) for one of two sampled residents (Resident 1). This deficient practice had a potential to result in the resident's responsible party being unaware of the bed hold policy and can lead to a transfer of the resident to another skilled nursing facility not of the resident's or responsible party's preference. Findings: During a review of the Resident 1's admission Record, it indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), ESRD (End Stage Renal Disease-irreversible kidney failure) and heart failure (a condition in which the heart does not pump blood as well as it should). The admission Record indicated, Resident 1 was discharged on 2/28/2025. During a review of the Minimum Data Set (MDS – resident assessment tool) dated 2/20/2025, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 required maximal assistance to total dependent 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). During a review of Resident 1's History and Physical (H&P) dated 2/21/2025, the H&P indicated, Resident 1 has the capacity to understand and make decisions. During a review of Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 2/27/2025, the SBAR indicated the physician's recommendation to send Resident 1 to GACH 1 due to nausea and vomiting of coffee ground emesis (the forceful ejection of some or all of the contents of the stomach through the mouth). 056334 Page 2 of 6 056334 04/01/2025 Beachwood Post-Acute & Rehab 1340 15th Street Santa Monica, CA 90404

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 1's Physician Order Summary and electronic and paper medical chart as of 4/1/2025, it indicated that there was no order for Bed-hold and no Bed-hold notice completed after Resident 1 was hospitalized on [DATE]. During an interview with the Assistant Director of Nursing (ADON) on 4/1/2025 at 2:11 p.m., ADON stated, there was no physician order for Resident 1's bed hold and there was no Bed hold notice completed after Resident 1's hospitalization. ADON stated, he was unsure of the facility's policy and procedure (P&P) on bed hold but there should be a notification of Bed-hold and documentation if bed-hold was offered to Resident 1 and/or Resident 1's responsible party. During an interview with Administrator (ADM) on 4/1/2025 at 3:29 p.m., Resident 1 did not have a Medi-cal (California's Medicaid program) insurance, and they don't put residents on bed hold if they don't have Medi-cal insurance. ADM stated, bed-hold notice, and bed hold information was not offered to Resident 1. During a review of the facility's policy and procedure (P&P) titled, Bed Hold (Medi-Cal) , revised on 1/2025, the P&P indicated, If the patient must be transferred to an acute hospital for seven days or less, our team will notify the patient or their representative that we are willing to hold the patient's bed. The patient or their representative have 24 hours after receiving this notice to let us know whether they want us to hold the bed for the patient . The benefit of the bed hold is that during the bed hold period, it provides the patient with an opportunity to return to their bed in the same facility after their hospital stay . Individuals who do not have Medi-Cal have the option to pay to hold the bed until the patient can return. 056334 Page 3 of 6 056334 04/01/2025 Beachwood Post-Acute & Rehab 1340 15th Street Santa Monica, CA 90404

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 ensure Resident 1 received quality of care and treatment in accordance with facility ' s policy and procedure titled, Acute Changes, to monitor Resident 1 after she had a change of condition (COC) on 2/23/2025. Residents Affected - Few This deficiency had the potential to result in poor quality of care and delayed response to resident needs after a COC. Findings: During a review of the Resident 1 ' s admission Record, it indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), ESRD (End Stage Renal Disease-irreversible kidney failure) and heart failure (a condition in which the heart does not pump blood as well as it should). During a review of the Minimum Data Set (MDS - resident assessment tool) dated 2/20/2025, indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 required maximal assistance to total dependent 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). During a review of Resident 1 ' s History and Physical (H&P) dated 2/21/2025, the H&P indicated, Resident 1 has the capacity to understand and make decisions. A review of Resident 1 ' s SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 2/23/2025 at 8:50 p.m., the SBAR indicated, Resident 1 complained of nausea and vomiting, Resident 1 vomited times (x) 3 during this shift . Resident 1 stated, she ' s still feeling nauseous. During a review of Resident 1 ' s Progress Notes on 2/24/2025 during morning (a.m.: 7:00 a.m. - 3:30 p.m.) shift and 2/25/2025, a.m. shift, there was no monitoring documented on Resident 1 ' s status after a COC. During a review of Resident 1 ' s SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 2/27/2025, the SBAR indicated the physician ' s recommendation to send Resident 1 to GACH 1 due to nausea and vomiting of coffee ground emesis (the forceful ejection of some or all of the contents of the stomach through the mouth). During an interview with Licensed Vocational Nurse (LVN 1) on 4/1/2025 at 11:00 a.m., LVN 1 stated, Resident 1 had a COC for nausea and vomiting. LVN 1 stated, she was assigned to Resident 1 during a.m. shift after Resident 1 had a COC but she does not remember Resident 1 ' s status and if she documented the monitoring assessment after Resident 1 had a COC. During a concurrent interview with Assistant Director of Nursing (ADON) and record review of Resident 1 ' s Progress Notes, ADON stated, Resident 1 had a COC on 2/23/2025 and again on 2/27/2025 for 056334 Page 4 of 6 056334 04/01/2025 Beachwood Post-Acute & Rehab 1340 15th Street Santa Monica, CA 90404

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few nausea and vomiting. ADON stated, residents with a COC must be monitored for 72-hour by charge nurses by all shifts and document a completed assessment. ADON stated, according to Resident 1 ' s progress notes, there was no monitoring done on 2/24/2025, a.m., and 2/25/2025 a.m. shift. During a review of the facility ' s policy and procedure (P&P) titled, Acute Condition Changes - Clinical Protocol, revised on 1/2025, the P&P indicated, The staff will monitor and document the resident's progress and responses to treatment, and the Physician will adjust treatment accordingly. The staff will notify responsible party for change of condition. During a review of the facility ' s P&P titled, Charting and Documentation, revised on 1/2025, the P&P indicated, All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record . All incidents, accidents, or changes in the resident's condition must be recorded and include follow up documentation entries if necessary. Based on interview and record review the facility failed to ensure Resident 1 received quality of care and treatment in accordance with facility's policy and procedure titled, Acute Changes , to monitor Resident 1 after she had a change of condition (COC) on 2/23/2025. This deficiency had the potential to result in poor quality of care and delayed response to resident needs after a COC. Findings: During a review of the Resident 1's admission Record, it indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), ESRD (End Stage Renal Disease-irreversible kidney failure) and heart failure (a condition in which the heart does not pump blood as well as it should). During a review of the Minimum Data Set (MDS – resident assessment tool) dated 2/20/2025, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 required maximal assistance to total dependent 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). During a review of Resident 1's History and Physical (H&P) dated 2/21/2025, the H&P indicated, Resident 1 has the capacity to understand and make decisions. A review of Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 2/23/2025 at 8:50 p.m., the SBAR indicated, Resident 1 complained of nausea and vomiting, Resident 1 vomited times (x) 3 during this shift . Resident 1 stated, she's still feeling nauseous. During a review of Resident 1's Progress Notes on 2/24/2025 during morning (a.m.: 7:00 a.m. – 3:30 p.m.) shift and 2/25/2025, a.m. shift, there was no monitoring documented on Resident 1's status after a COC. During a review of Resident 1's SBAR (situation, background, assessment, recommendation-a 056334 Page 5 of 6 056334 04/01/2025 Beachwood Post-Acute & Rehab 1340 15th Street Santa Monica, CA 90404

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few communication tool used by healthcare workers when there is a change of condition among the residents), dated 2/27/2025, the SBAR indicated the physician's recommendation to send Resident 1 to GACH 1 due to nausea and vomiting of coffee ground emesis (the forceful ejection of some or all of the contents of the stomach through the mouth). During an interview with Licensed Vocational Nurse (LVN 1) on 4/1/2025 at 11:00 a.m., LVN 1 stated, Resident 1 had a COC for nausea and vomiting. LVN 1 stated, she was assigned to Resident 1 during a.m. shift after Resident 1 had a COC but she does not remember Resident 1's status and if she documented the monitoring assessment after Resident 1 had a COC. During a concurrent interview with Assistant Director of Nursing (ADON) and record review of Resident 1's Progress Notes, ADON stated, Resident 1 had a COC on 2/23/2025 and again on 2/27/2025 for nausea and vomiting. ADON stated, residents with a COC must be monitored for 72-hour by charge nurses by all shifts and document a completed assessment. ADON stated, according to Resident 1's progress notes, there was no monitoring done on 2/24/2025, a.m., and 2/25/2025 a.m. shift. During a review of the facility's policy and procedure (P&P) titled, Acute Condition Changes - Clinical Protocol, revised on 1/2025, the P&P indicated, The staff will monitor and document the resident's progress and responses to treatment, and the Physician will adjust treatment accordingly. The staff will notify responsible party for change of condition. During a review of the facility's P&P titled, Charting and Documentation , revised on 1/2025, the P&P indicated, All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record . All incidents, accidents, or changes in the resident's condition must be recorded and include follow up documentation entries if necessary. 056334 Page 6 of 6