Health inspection·April 3, 2024

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure prompt attempt was made to resolve grievances for one of four sampled residents (Resident 1). This deficient practice violated Resident 1 ' s responsible party (R1 RP ' s) right to have grievances addressed and resolved. Findings: A review of Resident 1 ' s admission Record, indicated that Resident 1 was admitted to the facility on [DATE], with diagnoses including cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue), dysphagia (difficulty swallowing food or liquid) following cerebral infarction, and 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. A review of Resident 1's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 10/10/2023, indicated Resident 1 has severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and requiring maximal assistance from staff for activities of daily living (ADL-toileting hygiene, shower/bathing self, upper and lower body dressing, and personal hygiene). A review of Resident 1 ' s Progress Notes dated 3/17/2024 at 2:06 a.m. indicated, Resident 1 (family member) knocked on the facility ' s front door upset .yelled at health staff stated he was in front of the facility called several times to inquire about Resident 1 . ADM was notified and made aware of the situation. During an interview with Resident 1 ' s Emergency Contact (R1EC) on 4/3/2024 at 10:08 a.m., R1EC stated that he went to see Resident 1 on 3/17/2024 and went around 1:00 a.m., to check on the facility. R1EC stated, the staffs in the facility did not answer the phone call and the Licensed Vocational Nurse 1 (LVN 1) was rude and unprofessional on how she talked to him that night. R1EC further stated, he talked to the management staffs such as the Administrator and Social Services Director about the incident. During an interview with LVN 1 on 4/3/2024 at 11:54 a.m., LVN 1 stated, R1EC went to the facility around 1:00 a.m., and was yelling at the nurses. LVN 1 stated, the R1EC told her that he was calling, and they were not answering the phone. LVN 1 stated, she did not hear the phone ring and was busy administering medications to the residents. LVN 1 stated, she mentioned the incident to the Page 1 of 2 555054 555054 04/03/2024 Pacific Post Acute 1323 17th Street Santa Monica, CA 90404

F 0585 management the next day. Level of Harm - Minimal harm or potential for actual harm During an interview with Social Service Director (SSD), on 4/3/2024 at 12:14 p.m., SSD stated, she had talked to R1EC multiple times regarding his concerns regarding Resident 1. SSD stated, she was aware of the incident when R1EC visited the facility during non-visiting hours around 1:00 p.m. and reported the incident with LVN 1 being rude and unprofessional. SSD further stated, during the first few days of admission, R1EC also reported his concern about the care being provided to Resident 1. SSD stated, she did not do any grievance report regarding these incidents, but she should have started a grievance. SSD stated, anyone can report a grievance and they need to follow-up so that they know that they are working on the concerns brought to them. Residents Affected - Few A review of the facility ' s policy and procedures (P&P), titled, Resident and Family Grievances, reviewed on 8/23/2023, the P&P indicated that it is the policy of this facility to support each resident ' s and family member ' s right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal . A resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their long-term care (LTC) facility stay .The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form. 555054 Page 2 of 2