Health inspection·July 15, 2025

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Let each resident or the resident's legal representative access or purchase copies of all the resident's records. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a copy of the records upon request for one of four sampled residents (Resident 1).This deficient practice violated the rights of Resident 1's legal representative to obtain a copy of the medical records.Findings:During a review of the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including hemiplegia and hemiparesis (loss of the ability to move in one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting left non-dominant side, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1's History and Physical dated 7/30/2022 indicated, Resident 1 can make needs known but cannot make medical decisions. During a review of the Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 11/1/2023, 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 maximal assistance to dependent from staffs 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 Limited Durable Power of Attorney (POA authorizes someone else to handle certain matters, such as finances or health care, on someone's behalf. If the power of attorney is durable, it remains in effect if the person becomes incapacitated for any reason, including illness and accidents) for healthcare indicated, Resident 1's family member 1 (FM 1) was Resident's 1 appointed POA, signed and dated on 4/29/2025. During a review of Resident 1's Attestation Regarding a Requested Use of Disclosure of Protected Health Information Potentially Related to Reproductive Health Care (a signed document where someone requesting health information), dated 5/2/2025, indicated that a request for release of medical records form was faxed to the facility on 5/2/2025 and a follow-up request was sent to the facility via mail on 2/6/2025. During an interview with Family Member 1 Legal Representative (FMLR 1) on 7/14/2025 at 11:08 a.m., FM 1 stated, he requested Resident 1's medical record on behalf of Resident 1's Family Member back in May 2025 but had not received any medical records from the facility up to this date, 7/14/2025. During an interview with the Medical Record Director (MRD) on 7/14/2025 at 12:39 p.m., the MRD stated, a request for release of medical records was sent via email to the facility for Resident 1. MRD stated they have not sent these medical records as she is waiting for approval. The MRD further stated that the release of medical records must be sent timely within 5-7 business days. During a review of facility's policy and procedure (P&P) titled, Release of Information, revised on 1/2025, the P&P indicated, The resident may initiate a request to release such information contained in his/her records and charts to anyone he/she wishes. Such requests will be honored only upon receipt of a written, signed, and dated request from the resident or representative (sponsor). A resident may have access to his or her records within five days (excluding weekend or Page 1 of 4 056334 056334 07/15/2025 Beachwood Post-Acute & Rehab 1340 15th Street Santa Monica, CA 90404

F 0573 holidays) of the resident's written or oral request. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 056334 Page 2 of 4 056334 07/15/2025 Beachwood Post-Acute & Rehab 1340 15th Street Santa Monica, CA 90404

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 3 and Resident 4) who are fed by enteral received appropriate treatment and services by failing to elevate the head of the bed while receiving formula through the gastrostomy tube (GT - a tube inserted through the abdomen that delivers nutrition directly to the stomach).This deficient practice had the potential to cause aspiration (inhalation of foreign materials) and can lead to pneumonia (a lung infection) for Resident 3 and Resident 4.Findings:1. During a review of the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), dysphagia (difficulty swallowing) and shortness of breath (an intense tightening in the chest, air hunger, difficulty breathing, breathlessness or a feeling of suffocation). During a review of the Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 6/20/2025, indicated Resident 3's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 3 required total dependence 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 3's Order Summary Report (OSR), dated 4/10/2025, indicated physician ordered, Enteral Feed Order every shift Enteral - elevate head of head (HOB) 30 - 40 degrees (unit of measurement) at all times during feedings and for 30 minutes post-administration of feedings. During a review of Resident 3's Care Plan, date initiated on 3/29/2024, indicated an intervention of, The resident needs the HOB elevated 45 degrees during and thirty minutes after tube feed. During an observation of Resident 3 on 7/14/2025 at 11:19 a.m., Resident 3 was in bed, receiving feeding via GT with a HOB at about 15 degrees up. During a concurrent observation and interview with Registered Nurse 1 (RN 1) on 7/14/2025 at 11:31 a.m., RN 1 observed Resident 3's HOB and stated and confirmed, Resident 3's HOB needs to be elevated as the HOB is very low. RN 1 stated, the HOB needs to be elevated at least 30-40 degrees while receiving TF. 2. 2. During a review of the admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including Parkinson's disease (a chronic brain disorder that causes movement problems, and can also affect mental health, sleep, and pain), respiratory failure, and dysphagia. During a review of the MDS dated [DATE], Resident 4's cognitive skills for daily decisions were severely impaired. The MDS indicated Resident 3 required total dependence from staff for ADLs. During a review of Resident 4's OSR, dated 7/4/2025, indicated physician ordered, Enteral Feed Order every shift, Enteral - elevate HOB 30 - 40 degrees at all times during feedings and for 30 minutes post-administration of feedings. During an observation of Resident 4 on 7/14/2025 at 11:26 a.m., Resident 4 was in bed lying on his left sideways, receiving feeding via GT with a HOB at less than 30 degrees, the HOB was almost in a flat position. During a concurrent observation and interview with RN 1 on 7/14/2025 at 11:36 a.m., RN 1 observed Resident 4's HOB and stated and confirmed, Resident 4's HOB is at about 20 degrees up and definitely needs to be higher. RN 1 stated, the HOB needs to be elevated at least 30-40 degrees while receiving TF as this put residents at risk of aspiration, choking, and emesis, among other complications. During an interview with Director of Nursing (DON) on 7/15/2025 at 12:30 p.m., DON stated, residents' HOB must be elevated to semi-Fowlers position (when a person is lying on their back with their upper body slightly raised. The head of the bed is lifted to an angle between 30 and 45 degrees) while receiving TF to prevent risk of aspiration. 056334 Page 3 of 4 056334 07/15/2025 Beachwood Post-Acute & Rehab 1340 15th Street Santa Monica, CA 90404

F 0693 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedures (P&P) titled, Enteral Feedings - Safety Precautions, revised on 1/2025, the P&P indicated, Elevate the head of bed (HOB) at least 30 degrees during tube feedings and at least one hours after feeding. Residents Affected - Few 056334 Page 4 of 4