Health inspection·July 22, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to honor one of the three sampled residents (Resident 2) rights by failing to administer her ordered topical medication Triamcinolone Acetonide External Cream 0.1 % (belongs to the class of medications that are synthetic steroids used to reduce inflammation and itching of the skin. It works by reducing swelling, redness, and itching associated with various skin conditions) to her right elbow.This deficient practice resulted in Resident 2 not being able to make her own decisions regarding her own medications.During a review of the admission record for Resident 3 indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including Acute and Chronic Respiratory Failure (ACRF-when the lungs can't adequately provide enough oxygen to the body or remove enough carbon dioxide, and this condition happens suddenly but also persists over an extended period), hypertension (HTN-high blood pressure), and Hyperlipidemia (HLD- a condition in which there are abnormally high levels of lipids [fats] in the blood)During a review of Resident 2's late entry nursing note dated 5/20/2025 at 10:41 am indicated, Seen by dermatologist during tx (treatment) rounds concerning the current right arm with non-descript. erythematous papules (small, raised, red bumps on the skin). Skin scrapping (a diagnostic procedure where a healthcare provider scrapes a small sample of skin cells from a lesion or affected area using a scalpel or similar blade. It is immensely useful in skin infections such as fungus, bacteria, or even scabies mite infections) result is negative (5/15/25). She recommends topical Clobetasol oint (ointment) but Rp (representative) refused to be applied. Respect the refusal. Will continue to monitor.During a review of Resident 2's physician notes with an effective date range of 7/7/2025 indicated, Resident 2 was alert and oriented x 4 (alert and oriented to person, place, time and event are evaluated and understood who they are, where they are, approximate date or part of the day, and what is happening).During a review of a physician's order dated 6/14/2025 indicated, Triamcinolone Acetonide External Cream 0.1 % (Triamcinolone Acetonide (Topical) Apply to Affected areas topically one time only for topical redness and itching for 1 Day right posterior elbow, LUA (left upper arm), anterior upper leg.During an observation and interview with Resident 2 on 7/22/2025 at 11:17 am, Resident 2 was observed to have approximately 1.5-inch circular cluster of a raised scaly rash which was light brown is color located just above her elbow. Resident 2 was unable to vocalize due to the tracheostomy (often referred to as a trach, is a surgically created opening in the windpipe (trachea) through the neck) but was able to move her lips for lip reading as well as nodding yes and no. Resident 2 stated that she did get itchy but got relief with the application of the ointment. During an interview with Treatment Nurse (TN) 2 on 7/22/2025 at 1:23 pm, TN 2 stated that Resident 2's rash was recurring (occurring often or repeatedly) in the same area. TN 2 stated that Resident 2 was seen by a dermatologist who diagnosed it as fungal dermatitis (a skin condition caused by fungi, often appearing as a red, itchy, and scaly rash) and was ordered Triamcinolone Acetonide External Cream 0.1 %. TN 2 stated that the Page 1 of 6 056334 056334 07/22/2025 Beachwood Post-Acute & Rehab 1340 15th Street Santa Monica, CA 90404

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility staff did not regularly apply the ordered ointment because Resident 2's RP was refusing the treatment. TN stated that Resident 2 was alert, oriented, and able to understand and make her own decisions. TN2 stated that she as well as the other facility staff did not ask the Resident if she wanted the treatment but accepted and respected the decision of Resident 2's RP even though they are not the resident's decision maker. TN2 admitted that by not allowing Resident 2 to decide if she wanted to have the ointment administered or not was noy allowing her to exercise her rights.During an interview with the Assistant Director of Nursing (ADON) on 7/22/2025 at 2:51 pm, the ADON stated that residents who are able to make their own decisions must be involved in their planning and administration of their own medications because that is their right.During a review of the Policy and Procedure (P&P) titled Resident Rights, revised 1/2025, the P&P indicated: Federal and state laws guarantee certain basic rights to all residents of this facility. Theserights include the resident's right to:- Be informed about what rights and responsibilities he or she has.- Choose a physician and treatment and participate in decisions and care planning.- Privacy and confidentiality.- Self-administer medication, if the interdisciplinary care planning team determines it is safe; and Refuse a transfer from a distinct pa rt within the institution. 056334 Page 2 of 6 056334 07/22/2025 Beachwood Post-Acute & Rehab 1340 15th Street Santa Monica, CA 90404

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 observation, interview, and record review, the facility failed to create an individualized care for one of three sampled residents (Resident 3) with specific goals and interventions for Resident 3's right upper arm and right groin rash. This deficient practice had the potential to result in worsening of Resident 3's rashDuring a review of the admission record for Resident 3 indicated Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), Chronic Respiratory Failure (CRF-when the lungs can't adequately provide enough oxygen to the body or remove enough carbon dioxide, and this condition persists over an extended period), and Hyperlipidemia (HLD- a condition in which there are abnormally high levels of lipids [fats] in the blood) During a review of history and physical (H&P- is a thorough assessment a doctor does to understand a patient's health. It involves asking about the patient's past and current health problems [the history] and then examining the patient's body to look for signs of illness [the physical examination], dated 6/13/2025 at 2 pm, indicated Resident 3 did not have capacity (he ability to understand information, make decisions, and communicate those decisions). During a review of Resident 3's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) dated 7/3/2025 at 2:52 pm, indicated, Noted rashes RT arm and RT upper leg scattered rashes Informed DR (Resident 3's physician}. During a review of Resident 3 ' s Minimum Data Set (MDS - a resident assessment tool) dated 7/10/2025, indicated Resident 3 had severe cognitive impairment (a person has great difficulty with thinking, learning, remembering, and making decisions, to the point where they can't live independently). The same MDS indicated Resident 3 was dependent on staff for his Activities of Daily Living such as: (ADLs- routine tasks/activities such as eating, oral hygiene, toileting hygiene, shower/bathe self, personal hygiene, lower/upper body dressing, putting on/taking off footwear). During a review of a physician's order dated 7/10/2025 indicated, skin scraping (a diagnostic procedure where a healthcare provider scrapes a small sample of skin cells from a lesion or affected area using a scalpel or similar blade. It is immensely useful in skin infections such as fungus, bacteria, or even scabies mite infections) one time only for one day During a review of Resident 3's SBAR dated 7/11/2025 at 8:28 pm, indicated, A new skin finding was noted by CNA (Certified Nursing Assistant) staff during daily skin check. Patient's (Resident 3) skin was examined by Tx (treatment) staff noting discoloration of the left outer forearm, skin intact with no sign of infection. MD (medical doctor) ordered monitor for skin breakdown, infection, or increase in size. During a review of Resident 3's care plan initiated 7/3/2025 indicated a focus of Skin: Resident has a body rash located (RT UPPER ARM and is at risk for pain or discomfort, skin breakdown, spreading and worsening of the rash, the interventions/tasks included:-Administer anti-pruritic medication as ordered.-Administer treatments as ordered and monitor for effectiveness.-Avoid the use of harsh detergents, soaps, fragrances, or other irritating substances.-Encourage to avoid scratching. During a concurrent observation of Resident 3 and interview with CNA 1 on 7/22/2025 at 12:24 pm, Resident 3 was observed to have a scattered papule appearing rashes to his right upper arm that were red brownish in color. The resident was also noted to have a few rashes to the right side of his groin which was also scattered, papule appearing, red brownish in color. CNA stated that she noticed the rash about two weeks prior. During a concurrent interview with Treatment Nurse (TN) 1 and record review of Resident 3's medical records on 7/22/2025 at 12:40 pm, TN 1 confirmed that Resident 3's rashes (right upper arm and right groin area) was first observed on 056334 Page 3 of 6 056334 07/22/2025 Beachwood Post-Acute & Rehab 1340 15th Street Santa Monica, CA 90404

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 7/3/2025 and that a skin scrape test was completed on 7/10/2025. During a review of the care plan initiated on 7/3/2025, TN 1 confirmed that the interventions which included administer anti-pruritic medications and treatments as ordered were not individualized and specific. TN 1 admitted that medications must be listed by name and ensure that the interventions are specific to each Resident. TN 1 stated that the potential of not individualizing an care plan could result in miscommunication or misinterpretation amongst Resident 3's healthcare providers and may impact care. during a review of the Policy and Procedure (P&P) titled Care Plans - Comprehensive, revised 1/2025, indicated the following policy statement, An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The same P&P policy interpretation and implementations included:Each resident's comprehensive care plan is designed to:a. Incorporate identified problem areas.b. Incorporate risk factors associated with identified problems.c. Build on the resident's strengths.d. Reflect the resident's expressed wishes regarding care and treatment goals.e. Reflect treatment goals, timetables and objectives in measurable outcomes.f. Identify the professional services that are responsible for each element of care.g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels.h. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; [NAME]. Reflect currently recognized standards of practice for problem areas and conditions. 056334 Page 4 of 6 056334 07/22/2025 Beachwood Post-Acute & Rehab 1340 15th Street Santa Monica, CA 90404

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement infection control policies and procedures (P&P) for one out of three residents (Resident 3) by failing to ensure Resident 3 who had a rash and was ordered a scrape test on 7/10/2025 was placed on contact isolation ( a set of precautions used in health care to prevent the spread of infections that are transmitted through direct or indirect contact with a patient or their environment).This deficient practice potentially increased the risk of infection to other residents and facility staff.During a review of the admission record for Resident 3 indicated Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), Chronic Respiratory Failure (CRF-when the lungs can't adequately provide enough oxygen to the body or remove enough carbon dioxide, and this condition persists over an extended period), and Hyperlipidemia (HLD- a condition in which there are abnormally high levels of lipids [fats] in the blood) During a review of history and physical (H&P- is a thorough assessment a doctor does to understand a patient's health. It involves asking about the patient's past and current health problems [the history] and then examining the patient's body to look for signs of illness [the physical examination], dated 6/13/2025 at 2 pm, indicated Resident 3 did not have capacity (he ability to understand information, make decisions, and communicate those decisions). During a review of Resident 3's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) dated 7/3/2025 at 2:52 pm, indicated, Noted rashes RT arm and RT upper leg scattered rashes Informed DR (Resident 3's physician}. During a review of Resident 3 ' s Minimum Data Set (MDS - a resident assessment tool) dated 7/10/2025, indicated Resident 3 had severe cognitive impairment (a person has great difficulty with thinking, learning, remembering, and making decisions, to the point where they can't live independently). The same MDS indicated Resident 3 was dependent on staff for his Activities of Daily Living such as: (ADLs- routine tasks/activities such as eating, oral hygiene, toileting hygiene, shower/bathe self, personal hygiene, lower/upper body dressing, putting on/taking off footwear). During a review of a physician's order dated 7/10/2025 indicated, skin scraping (a diagnostic procedure where a healthcare provider scrapes a small sample of skin cells from a lesion or affected area using a scalpel or similar blade. It is immensely useful in skin infections such as fungus, bacteria, or even scabies mite infections) one time only for one day During a review of Resident 3's SBAR dated 7/11/2025 at 8:28 pm, indicated, A new skin finding was noted by CNA (Certified Nursing Assistant) staff during daily skin check. Patient's (Resident 3) skin was examined by Tx (treatment) staff noting discoloration of the left outer forearm, skin intact with no sign of infection. MD (medical doctor) ordered monitor for skin breakdown, infection, or increase in size. During a concurrent observation of Resident 3 and interview with CNA 1 on 7/22/2025 at 12:24 pm, Resident 3's room entrance was observed to have a sign for Enhance Based Precautions (EBPimplemented in nursing homes to reduce the spread of multidrug-resistant organisms [MDROs]. Staff are required to use gowns and gloves during high contact activities with residents). Resident 3 was observed to have a scattered papule appearing rashes to his right upper arm that were red brownish in color. The resident was also noted to have a few rashes to the right side of his groin which was also scattered, papule appearing, red brownish in color. CNA stated that she noticed the rash about two weeks prior. During a concurrent interview with Treatment Nurse (TN) 1 and record review of Resident 3's medical records on 7/22/2025 at 12:40 pm, TN 1 confirmed that Resident 3's rashes (right upper arm and right groin area) was first observed on 7/3/2025 and that a skin scrape test Residents Affected - Few 056334 Page 5 of 6 056334 07/22/2025 Beachwood Post-Acute & Rehab 1340 15th Street Santa Monica, CA 90404

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was completed on 7/10/2025. TN 1 confirmed that a skin scrape test was ordered to rule out scabies. TN 2 confirmed that scabies are contagious and must be on contact precautions. TN 1 admitted that EBP precautions may not be enough tp prevent the spread of infection. During a concurrent interview and record review of Resident 3's records with the Assistant Director of Nursing (ADON) on 7/22/2025 at 2:51 pm, the ADON confirmed that a scrape skin test was completed for Resident 3 on 7/10/2025. ADON confirmed that Resident was in EBP even after the scare test was ordered and completed. The ADON was not aware about the procedures of placing residents on contact isolation when a scrape test was ordered, stating that the resident was already on EBP. The ADON confirmed that when a resident is on EPB the PPE (Personal Protective Equipment-gown, gloves) are donned during personal high contact activities, while in contact isolation the PPE is donned before entering the room. The ADON confirmed that the facility also follows CDC (Centers for Disease Control and Prevention) guidelines. During a review of the Policy and Procedure (P&P) titled Infection Control, effective date 4/1/2025, indicated, it is the policy of this facility to prevent the spread of infection. Standard Precautions will be used when caring for residents at all times regardless of their suspected or confirmed infection status. Transmission-Based Precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others. 056334 Page 6 of 6