Health inspection·September 5, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility failed to: 1. Ensure one of four sampled residents (Resident 1)'s medications were not left at bedside after administering them according to facility's policy and procedures (P&P) titled, Administering Medications. 2. Ensure that one of four sampled residents (Resident 1 and Resident 2)'s medications were administered in accordance with the physician's orders, including any required time frame according to facility's P&P, titled, Administering MedicationsThis deficient practice increased the risk for accidents, unintended complications from receiving more or less than the required medications dose and jeopardized resident's health and safety by failing to administer necessary medications in accordance with the physician order.Findings:1. During a review of the admission Record, Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide) and chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure).During a review of the Minimum Data Set (MDS - resident assessment tool) dated 8/1/2025 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 assistant 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 Medical Record, the facility did not do a Self-Administration of Medication Observation Assessment on Resident 1 upon readmission on [DATE].During a review of Resident 1's Order Summary Report (OSR), the OSR indicated the following medications:i. Sevelamer Carbonate (a medication that prevents increases in phosphates among people who are on dialysis due to chronic kidney disease) tablet 800 milligram (mg - unit of measurement) - give three tablets by mouth three times a day ii. Combigan opthlmalmic solution (a prescription eye drop medication that helps lower pressure inside the eye) 0.2-0.5 percent (% - unit of measurement) - Instill one drop in both eyes two times a day for glaucoma (a group of eye diseases that damage the optic nerve, which carries visual information from the eye to the brain)During a review of Resident 1's Medication Administration Audit Record (MAAR) on 9/5/2025, the MAAR indicated that the sevelamer carbonate tablets were scheduled to be administered at 9 a.m., but the record indicated, the medications were administered on 10:33 a.m. The MAAR also indicated that on 9/4/2025, the combigan eyedrops were scheduled to be administered at 9 a.m., but the record indicated, the combigan were administered at 3:38 p.m.During a concurrent observation and interview with Resident 1 on 9/5/2025 at 11:29 a.m., observed Resident 1 with a medication cup filled with three white tablets at her bedside table. Resident 1 stated she did not take the medications after they were given to her because she wanted to take them before eating lunch. Resident 1 stated that the nurse gave her Page 1 of 3 056334 056334 09/05/2025 Beachwood Post-Acute & Rehab 1340 15th Street Santa Monica, CA 90404

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the medication, and they don't observe when she takes the medication. Resident 1 further stated, sometimes, her medications were being administered late and they don't follow the physician's order for the time frame the medications were due.During a concurrent observation and interview with Licensed Vocational Nurse 1 (LVN 1) on 9/5/2025 at 11:39 a.m., LVN 1 stated, he administered Resident 1's medications this morning but he left Resident 1's room without observing her taking the medications. LVN 1 stated, he was called and was in a hurry and did not watch Resident 1 taking the medication after giving it to her. LVN 1 stated, he also documented the medications as administered in the electronic medical record. LVN 1 compared the three white tablets with the medications in the bubble pack and stated, the three white tablets on Resident 1's medication cup were sevelamer carbonate.During an interview with the Director of Nursing (DON) on 9/5/2025 at 3:02 p.m., DON stated, medications should not be left at bedside, and nurses must witness residents taking the medications. DON stated, if a resident refuses to take the medication at the time when it was scheduled, nurses need to explain the risk and benefits of not taking the medication timely and document the refusal and notify the physician. DON stated that not giving the medication on time was a delay of patient's care that may interfere with residents' recovery process and plan of care. 2. During a review of the admission Record, Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) affecting left non-dominant side, acute respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide) and DM. During a review of the MDS dated [DATE], Resident 2's cognitive skills for daily decisions were intact. The MDS indicated Resident 1 required maximal assistant to total dependent from staff for ADLs.During a review of Resident 2's OSR, the OSR indicated the following medications were scheduled to be administered at 9 a.m.:i. Thiamine (a B-vitamin that helps your body turn food into energy and is essential for a healthy nervous system and heart) oral tablet 100 mg - give one tablet by mouth one time a day for supplementii. Lactobacillus (a probiotic supplement containing good or friendly bacteria that help restore a healthy balance of microbes in your body) capsule - give one tablet by mouth one time a dayiii. Modafinil (a prescription drug that promotes wakefulness) oral tablet 100 mg - give 100 mg by mouth one time a dayiv. Sertraline (a prescription antidepressant that works by adjusting your brain's chemistry to improve mood and reduce anxiety) oral tablet 25 mg - give 50 mg by mouth one time a dayv. Furosemide (a water pill that works by making your kidneys remove extra water and salt from your body) oral tablet 20 mg - give 20mg by mouth one time a dayvi. Midodrine (a medication used to treat very low blood pressure) oral tablet 5 mg - give 5 mg by mouth three times a dayvii. Multivitamin-minerals (contains a mix of different vitamins and minerals, which are essential nutrients your body needs to function properly) oral tablet - give one tablet by mouth one time a dayviii. Senna (a laxative that helps relieve occasional constipation by making your intestines more active) oral tablet 8.6 mg - give 8.6 mg by mouth two times a dayix. Ascorbic acid (a supplement form of Vitamin C, a nutrient your body needs to stay healthy) oral tablet 500 mg - give 500 mg tablet by mouth two times a dayx. Folic acid (a B-vitamin that helps your body create new, healthy cells) oral tablet 1 mg - give 1 mg by mouthy one time a day During a review of Resident 2's MAAR, dated 9/4/2025, the MAAR indicated that the medications that were scheduled to be administered at 9 a.m., were recorded as administered at 11:34 a.m.During a concurrent interview and record review with DON on 9/5/2025 at 3:10 p.m., DON reviewed Resident 2's MAAR and confirmed, Resident 2's medications were administered late. DON stated, medications must be administered timely per physician's order. DON further stated that not giving the medication on time was a delay of patient's care that may interfere with residents' recovery process and plan 056334 Page 2 of 3 056334 09/05/2025 Beachwood Post-Acute & Rehab 1340 15th Street Santa Monica, CA 90404

F 0755 Level of Harm - Minimal harm or potential for actual harm of care.During a review of the facility's policy and procedures (P&P) titled, Administering Medications, reviewed on 1/2025, the P&P indicated, Medications must be administered in accordance with the orders, including any required time frame. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. Residents Affected - Some 056334 Page 3 of 3