Health inspection·February 26, 2024

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that one of four sampled residents (Resident 1) had a change in condition (COC) assessment completed when Resident 1 ' s pressure ulcer/injury (damaged skin caused by staying in one position for too long) in the sacrococcyx (in human anatomy, is a large, triangular bone at the base of the spine) was changed from unstageable (UTD - unable to determine or unstageable pressure ulcer defined as Stage 3 or 4) to Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer. This deficient practice had the potential to result a negative impact on residents ' health and safety, as well as the quality of care and services received. Findings: A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including type II diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure) and respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide). A review of Resident 1's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool) dated 2/4/2024, indicated Resident 1 ' s cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired for daily decision-making and required maximal assistance to dependent from staff for activities of daily living (ADL- eating, oral hygiene, toileting hygiene, shower/bathe and personal hygiene). The same MDS indicated, Resident 1 is at high risk of developing pressure ulcers/injuries. A record review of Resident 1 ' s Skin Only Evaluation dated 12/19/2023 indicated, Resident 1 ' s sacrococcyx pressure ulcer/injury was unstageable with measurement of 11.1 centimeter (cm) length by 10.2 cm width with depth undetermined. A record review of Resident 1 ' s Skin Only Evaluation dated 12/21/2023 indicated, Resident 1 ' s sacrococcyx pressure ulcer/injury was unstageable with measurement of 11.2 cm length by 10.4 cm width with depth undetermined. A record review of Resident 1 ' s Skin Only Evaluation dated 12/26/2023 indicated, Resident 1 ' s sacrococcyx pressure ulcer/injury was now a stage 4 with measurement of 11 cm length by 11.2 cm width x 3.0 cm depth, with 6.3 cm tunneling (a wound that has progressed to form an opening underneath Page 1 of 5 555054 555054 02/26/2024 Pacific Post Acute 1323 17th Street Santa Monica, CA 90404

F 0636 the surface of the skin). Level of Harm - Minimal harm or potential for actual harm A review of Resident 1 ' s medical record as of 2/26/2024 indicated, there was no COC and no Interdisciplinary Team (IDT - a group of dedicated healthcare professionals who work to bring knowledge together to help residents receive the care they need) meeting developed when Resident 1 ' s sacrococcyx pressure ulcer was changed to Stage 4 as noted by the Wound Care Specialist (WCS) on 12/26/2023. Residents Affected - Few During an interview with Infection Preventionist Nurse / Treatment Nurse (IPN/TXN) on 2/26/2023 at 5:09 p.m., IPN/TXN stated, when the WCS indicated the sacrum was now a stage 4, the facility should have done a COC and IDT meeting so that they can provide the appropriate care and services needed for Resident 1 ' s pressure ulcer. A review of the facility ' s policy and procedure (P&P) titled, Pressure Injury Prevention Guidelines, revised on 11/27/2023, the P&P indicated, individualized interventions will address specific factors identified in the resident ' s risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). The same P&P also indicated, the effectiveness of interventions will be monitored through ongoing assessment of the resident and/or wound. Considerations for needed modifications include: a. Development of a new pressure injury. b. Lack of progression towards healing or changes in wound characteristics. c. Changes in the resident ' s goals and preferences, such as at end-of-life or in accordance with his/her rights. A review of the facility ' s P&P titled, Pressure Injury Prevention and Management, revised on 9/12/2023, the P&P indicated, the facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate . Monitoring a. The attending physician will be notified of: i. The presence of a new pressure injury upon identification. ii. The progression towards healing, or lack of healing, of any pressure injuries weekly as needed. iii. Any complications (such as infection, development of a sinus tract, etc.) as needed Modifications of Interventions: a. Any changes to the facility ' s pressure injury prevention and management processes will be communicated to relevant staff in a timely manner. b. Interventions on a resident ' s plan of care will be modified as needed. Considerations for 555054 Page 2 of 5 555054 02/26/2024 Pacific Post Acute 1323 17th Street Santa Monica, CA 90404

F 0636 needed . Level of Harm - Minimal harm or potential for actual harm Modifications include: i. Changes in resident ' s degree of risk for developing a pressure injury. Residents Affected - Few ii. New onset or recurrent pressure injury development. iii. Lack of progression towards healing. iv. Resident non-compliance. v. Changes in the resident ' s goals and preferences, such as at end-of-life or in accordance with his/her rights. 555054 Page 3 of 5 555054 02/26/2024 Pacific Post Acute 1323 17th Street Santa Monica, CA 90404

F 0760 Ensure that residents are free from significant medication errors. 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, facility failed to ensure one of four sampled residents (Resident 4) was free from medication error by failing to ensure the medications were given on time as ordered by the physician. Residents Affected - Some This deficient practice jeopardized Resident 4 ' s health and safety by failing to administer necessary medications in accordance with the physician order. Findings: A review of Resident 4 ' s admission Record indicated resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including atrial fibrillation (afib- an irregular and very rapid heart rhythm that and can lead blood clots in the heart), major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), and polyneuropathies (a condition in which a person's peripheral nerves are damaged). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 1/30/2024, indicated Resident 4 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was moderately impaired. The MDS indicated Resident 1 required moderate assistance from staffs for activities of daily living (ADLs – toileting hygiene, shower/bathe, upper and lower body dressing, and personal hygiene). During a concurrent observation and interview with Registered Nurse 1 (RN 1) on 2/26/2024 at 11:23 a.m., RN 1 was observed reviewing Resident 4 ' s MAR and stated she was getting ready to administer Resident 4 ' s morning medications. RN 1 stated, her (Resident 4) medication was scheduled for 9:00 a.m., but Resident 4 was asleep on the time the medications were scheduled so she did not try to wake Resident 4 or offer her morning medications. RN 1 further stated, according to their policy, the medications should be given one hour before and after the scheduled time and since she was about to administer it, it would be a medication error because it is almost 12:00 p.m. A record review of Resident 4 ' s Medication Administration Record (MAR) dated 2/26/2024, ordered to be administered in the morning at 9:00 a.m., indicated medications were administered at 11:28 a.m. instead for the following medications: Amlodipine besylate (can treat high blood pressure and chest pain) oral tablet 10 mg – give 1 tablet by mouth one time a day Apixaban (used to treat and prevent blood clots and to prevent stroke) oral tablet 2.5 mg – give 1 tablet by mouth two times a day Aspirin (can treat pain, fever, headache, and inflammation, it can also reduce the risk of heart attack) 81 mg oral tablet – give 1 tablet by mouth one time a day Cranberry (supplement used for reducing the risk of bladder infections) oral tablet 250 mg – give 1 tablet by mouth two times a day 555054 Page 4 of 5 555054 02/26/2024 Pacific Post Acute 1323 17th Street Santa Monica, CA 90404

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Duloxetine (can treat depression, anxiety) oral capsule delated release sprinkle 30 mg – give 2 capsule by mouth one time a day Lidocaine (used to relieve pain) patch 5 percent (%) – apply to right hip topically one time a day Magnesium hydroxide (can treat constipation, upset stomach, and heartburn) oral suspension 400mg / 5 millimeter (ml) – give 30 ml by mouth two times a day Polyethylene powder (made for providing gentle constipation relief) – give 17 gram by mouth two times a day Senna (used to relieve occasional constipation) oral tablet 8.6 mg – give 2 tablet by mouth two times a day. During a follow-up interview with RN 1 on 2/26/2024 at 3:16 p.m., RN 1 stated and confirmed, Resident 4 ' s morning medications were administered late, and the physician was not notified of the late medication administration and a change of condition was not completed either. During an interview with Director of Nursing (DON) on 2/26/2024 at 3:57 p.m., DON stated, the medications are to be administered an hour before and an hour after of the scheduled time. DON stated, if a reside refuses medications twice, the physician must be notified. DON further stated, the medications are given later, they need to document when the medications were given, and complete a change of condition. A review of the facility ' s policy and procedures (P&P) titled, Medication Administration, reviewed 12/19/2022 indicated, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection . administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. 555054 Page 5 of 5