Health inspection·June 3, 2024

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to promote resident's rights to be given an advanced notice when the room and/or roommate changes was performed for three of three sampled residents (Resident 1, 2, 3) as indicated in the facility's policy and procedure titled, Change of Room or Roommate . This deficient practice violated the residents' right to make an informed decision regarding room/roommate changes. Findings: 1. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), 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 muscle weakness. During a review of the Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated 4/15/2024, indicated Resident 1's cognitive skill (mental action or process of acquiring knowledge and understanding) for daily decision-making were intact and required moderate assistance from staff for activities of daily living (ADL-toileting hygiene, shower/bathing, upper and lower body dressing and repositioning from sit to stand, sit to lying and rolling left and right). A review of Resident 1's Care Plan (CP) for mood problem related to (r/t) anxiety (feeling of worry), revised on 5/15/2024 indicated a goal of resident (1) will have improved mood state happier, calmer appearance, no signs/symptoms (s/sx) of depression, anxiety or sadness. A review of the facility census on 5/23/2024 indicated, Resident 1 was roommate with Resident 2. The facility census on 5/24/2024 indicated, Resident 1 was roommate with Resident 3. A review of the facility's Roommate Change Consent Form as of 6/3/2024 indicated, there was no Roommate Change Consent form/Notification was documented. A review of Resident 1's Progress Notes, dated 5/24/2024, the Progress Notes indicated that Resident (1) informed staff that roommate was not appropriate fit and requested a room change. During an interview with Resident 1 on 6/3/2024 at 10:39 a.m., Resident 1 stated that she had multiple previous roommates who were not compatible with her. Resident 1 stated, her previous roommates, Page 1 of 7 555054 555054 06/03/2024 Pacific Post Acute 1323 17th Street Santa Monica, CA 90404

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 2 and Resident 3 both have behavior issues who tend to yell and scream especially at night which caused her not to get enough sleep. Resident 1 stated, she would notify staff about it. Resident 1 further stated, because she was unable to get enough sleep, she felt sick on multiple occasion. 2. A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood), major depressive disorder, and heart failure (a condition in which the heart does not pump blood as well as it should). During a review of the MDS dated [DATE], indicated Resident 2's cognitive skill for daily decision-making were moderately impaired and required maximal assistance from staff for ADLs-toileting hygiene, shower/bathing, upper and lower body dressing and repositioning from sit to stand, sit to lying and rolling left and right. 3. 2. A review of Resident 3's admission Record indicated Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including COPD, major depressive disorder and dementia (loss of cognitive functioning-thinking, remembering, and reasoning). During a review of the MDS dated [DATE], indicated Resident 3's cognitive skill for daily decision-making were moderately impaired and required maximal assistance to total dependence from staff for ADLs-toileting hygiene, shower/bathing, lower body dressing and repositioning from sit to stand and sit to lying. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 6/3/2024 at 11:16 a.m., LVN 1 stated, Resident 2 is forgetful and has chronic pain and screams out when in pain even after giving pain medications. LVN 1 stated, Resident 3 is incoherent and mumbles even when redirected. During an interview with Licensed Vocational Nurse 2 (LVN 2) on 6/3/2024 at 12:44 p.m., LVN 2 stated, Resident 3 have episodes of aggressiveness and sundowning (a group of symptoms that many people with dementia get in the late afternoon and early evening. It includes confusion, trouble sleeping, anxiety, wandering, and hallucinations). LVN 2 stated, Resident 3 also have sundowning episodes that residents from their rooms in the adjacent hallway can hear them when they yell and screams at night. LVN 2 further stated, Resident 1 both had Resident 2 and Resident 3 as her (Resident 1)'s roommates and she was very vocal about her concerns when it comes to her roommate. During a concurrent interview with Director of Nursing (DON) and record review of the facility's room changes consent form documents on 6/3/2024 at 12:58 p.m., there was no room changes consent and written documentations regarding the room changes done. DON stated, she spoke with Social Services Director (SSD) in which SSD indicated, the grievance forms binder was not updated. DON further stated, they are not following their policies. A review of the facility's policy and procedure titled, Change of Room or Roommate , reviewed/revised on 4/17/2024, the P&P indicated that the facility reserves the right to make resident room changes or roommate assignments when found to be necessary by the facility or when requested by the resident. Reasons for a change in room or roommate could include, but are not limited to: incompatibility of residents in a shared room. The same P&P also indicated, prior to making a room change or roommate assignment, all persons involved in the change/assignment, such as residents and their 555054 Page 2 of 7 555054 06/03/2024 Pacific Post Acute 1323 17th Street Santa Monica, CA 90404

F 0559 Level of Harm - Minimal harm or potential for actual harm representatives, will be given advance notice of such a change as is possible . The notice of a change in room or roommate will be provided in writing, in language and manner the resident and representative understand and will include the reason(s) why the move or change is required. Residents Affected - Some 555054 Page 3 of 7 555054 06/03/2024 Pacific Post Acute 1323 17th Street Santa Monica, CA 90404

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 right to have grievances addressed. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), 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 muscle weakness. During a review of the Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated 4/15/2024, indicated Resident 1's cognitive skill (mental action or process of acquiring knowledge and understanding) for daily decision-making were intact and required moderate assistance from staff for activities of daily living (ADL-toileting hygiene, shower/bathing, upper and lower body dressing and repositioning from sit to stand, sit to lying and rolling left and right). A review of Resident 1's Care Plan (CP) for mood problem related to (r/t) anxiety (feeling of worry), revised on 5/15/2024 indicated a goal of resident (1) will have improved mood state happier, calmer appearance, no signs/symptoms (s/sx) of depression, anxiety or sadness. A review of the facility's Grievances Form as of 6/3/2024 indicated, there was no Grievance Form was completed for Resident 1. During an interview with Resident 1 on 6/3/2024 at 10:39 a.m., Resident 1 stated that she had multiple previous roommates who were not compatible with her. Resident 1 stated, her previous roommates, Resident 2 and Resident 3 both have behavior issues who tend to yell and scream especially at night which caused her not to get enough sleep. Resident 1 stated, she notified staff about it and the management heads were aware. Resident 1 further stated, because she was unable to get enough sleep, she felt sick on multiple occasion. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 6/3/2024 at 11:16 a.m., LVN 1 stated, Resident 2 is forgetful and has chronic pain and screams out when in pain even after giving pain medications. LVN 1 stated, Resident 3 is incoherent and mumbles even when redirected. During an interview with Licensed Vocational Nurse 2 (LVN 2) on 6/3/2024 at 12:44 p.m., LVN 2 stated, Resident 3 have episodes of aggressiveness and sundowning (a group of symptoms that many people with dementia get in the late afternoon and early evening. It includes confusion, trouble sleeping, anxiety, wandering, and hallucinations). LVN 2 stated, Resident 3 also have sundowning episodes that residents from their rooms in the adjacent hallway can hear them when they yell and screams at night. LVN 2 further stated, Resident 1 both had Resident 2 and Resident 3 as her (Resident 1)'s roommates and she was very vocal about her concerns when it comes to her roommate. LVN 2 stated, he informed the Social Services and management regarding Resident 1's concern. 555054 Page 4 of 7 555054 06/03/2024 Pacific Post Acute 1323 17th Street Santa Monica, CA 90404

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview with Director of Nursing (DON) and record review of the facility's grievances form, DON stated, there was no grievance completed Resident 1's concerns. DON stated, she spoke with Social Services Director (SSD) in which SSD indicated, the grievance forms binder was not updated. A review of the facility's policy and procedure titled, Resident and Family Grievances , reviewed/revised on 4/17/2024, the P&P indicated that it is the policy of the facility to support each resident's and family's right to voice grievances without decimation, 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 same P&P also indicated, evidence demonstrating the results of all grievances will be maintained for a period of no less than 3 years from the issuance of the grievance decision. 555054 Page 5 of 7 555054 06/03/2024 Pacific Post Acute 1323 17th Street Santa Monica, CA 90404

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide social services to one out of four sampled residents (Resident 1) by failing to provide necessary social services referrals. Residents Affected - Few This deficient practice had the potential for delay in the delivery of care and services. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), 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 muscle weakness. A review of the Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated 4/15/2024, indicated Resident 1's cognitive skill (mental action or process of acquiring knowledge and understanding) for daily decision-making were intact and required moderate assistance from staff for activities of daily living (ADL-toileting hygiene, shower/bathing, upper and lower body dressing and repositioning from sit to stand, sit to lying and rolling left and right). A review of Resident 1's Care Plan (CP) for mood problem related to (r/t) anxiety (feeling of worry), revised on 5/15/2024 indicated a goal of resident (1) will have improved mood state happier, calmer appearance, no signs/symptoms (s/sx) of depression, anxiety or sadness. A review of the facility's Roommate Change Consent Form as of 6/3/2024 indicated, there was no Roommate Change Consent form/Notification was documented since 2023. A review of the facility's Grievance Form Binder as of 6/3/2024 indicated, there was no Grievance Form documented for 2024. During an interview with Resident 1 on 6/3/2024 at 10:39 a.m., Resident 1 stated that she had multiple previous roommates who were not compatible with her. Resident 1 stated, her previous roommates, Resident 2 and Resident 3 both have behavior issues who tend to yell and scream especially at night which caused her not to get enough sleep. Resident 1 stated, she notified staff about it and the management heads were aware. Resident 1 further stated, because she was unable to get enough sleep, she felt sick on multiple occasion. During a concurrent interview with Director of Nursing (DON) and record review of the facility's room changes consent form/notification form and grievances documents on 6/3/2024 at 12:58 p.m., there was no room changes consent and written documentations regarding the room changes done since 2023 and there no grievances form completed for 2024. DON stated, she spoke with Social Services Director (SSD) in which SSD indicated, the grievance forms binder and room changes notification forms were not updated. DON further stated, they are not following their policies. A review of the facility's policy and procedure (P&P) titled, Referrals , reviewed/revised on 4/17/2024, the P&P indicated that Social Services shall coordinate most resident referrals. Social 555054 Page 6 of 7 555054 06/03/2024 Pacific Post Acute 1323 17th Street Santa Monica, CA 90404

F 0745 services will coordinate with the nursing staff or other pertinent disciplines to arrange for services. Level of Harm - Minimal harm or potential for actual harm A review of the facility's Job Description, titled, Social Service Designee , undated, indicated that the primary purpose of job position is to assist in planning, developing, organizing, implementing, evaluating, and directing social service programs in accordance with current existing federal, state, and local standards, as well as our established policies and procedures, to assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis. Residents Affected - Few 555054 Page 7 of 7