Health inspection·September 5, 2025

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide an effective discharge for one of three sampled residents, (Resident) 1 with a safe and orderly discharge planning by failing to:1.Ensure the facility's policy and procedure (P&P), titled, Discharge Planning Process, was applied by ensuring an effective discharge planning process that addressed the discharge destination met Resident 1's health and safety needs and preferences.2. Ensure Resident 1's care plan for discharge was implemented.3. Ensure that the discharge notice is provided to the resident's representative and Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) in a language and manner in which they can understand at least 30 days prior to discharging Resident 1.These deficient practices resulted in unsafe discharge setting that led to Resident 1's physical harm and hospitalization, Resident 1 was home alone for six days without any necessary care, Resident 1 was found on the floor with injury and was sent to General Acute Care Hospital 1 (GACH 1) on 9/1/2025.During a review of Resident 1's admission Record, it indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including Parkinson's disease (a chronic brain disorder that causes movement problems, and can also affect mental health, sleep, and pain), infection and inflammation reaction due to internal left knee prosthesis (germs have gotten into the joint, causing the body's immune system to attack), type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), acquired absence of left leg above knee (loss of left leg above the knee due to amputation or other causes), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure). The admission Record also indicated that Resident 1 was discharged home on 8/26/2025.During a review of the medical record from General Acute Care Hospital 2 (GACH 2) indicated the following:i. On 6/30/2025, Resident 1 had a revision left above the knee amputation (to correct any complications that arise after primary amputation surgery).ii. Occupational Therapy Evaluation, dated 7/1/2025, indicated, support available: Friend - has a friend that has historically helped her (Resident 1) as needed but may not be able to provide as much as he used to due to his own health issues; homemaking assistant: needs assistance.iii. Physical Therapy Treatment, dated 7/2/2025, indicated that Resident 1 had a non-weight bearing (you cannot place any of your body weight on an injured limb, such as a leg or arm, for a specific period to allow it to heal) on left lower extremity (left leg).iv. Referral Notes from GACH 2, dated 7/3/2025, it indicated, Resident 1 has physical limitations such as deconditioning (when a person is immobile for an extended period of time), frailty (when your body can't get through and recover from illnesses and injuries on its own), malnutrition (lack of sufficient nutrients in the body) or other physical limitation that impair ability to participate in their care, has poor health literacy (the inability to get, process, and understand basic health information and services needed to make Page 1 of 5 555054 555054 09/05/2025 Pacific Post Acute 1323 17th Street Santa Monica, CA 90404

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few good health decisions) and no patient support with social isolation, absence of support to assist with care, as well as insufficient or absent connection with primary care. During a review of Resident's History and Physical (H&P), dated 7/4/2025, it indicated that Resident 1 does not have a decision-making capacity. The H&P also indicated that, Emergency Contact 1 (EC1) is Resident 1's Durable Power of Attorney (POA authorizes someone else to handle certain matters, such as finances or health care, on someone's behalf. If the power of attorney is durable, it remains in effect if the person becomes incapacitated for any reason, including illness and accidents).During a review of Resident 1's Durable Power of Attorney, indicated Resident 1's EC1 was Resident's 1 appointed POA, signed and dated on 10/10/2024.During a review of the Minimum Data Set (MDS - resident assessment tool) dated 8/26/2025, 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 moderate assistance from staff for activities of daily living (ADLsroutine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS also indicated Resident 1 used a manual wheelchair.During a review of Resident 1's Care Plan (CP) for discharge, initiated on 7/9/2025, the CP indicated a goal of, Resident (1) will move to an appropriate lower level of care without complication and when appropriate. The CP included interventions such as, facility will provide education to resident/family regarding referrals, community resources and resident and/or family will be involved in discharge planning.During a review of Resident 1's Progress Notes, dated 8/22/2025, it indicated that, Per resident (Resident 1) request, she will discharge home on 8/26/2025, HHA 1 will follow-up for nursing, physical therapy (PT) and Occupation Therapy (OT) services, documented by Social Services Director (SSD).During a review of Resident 1's Post-Discharge Plan of Care and Summary (PDPOCS), dated 8/27/2025, it indicated that Resident 1 was discharged home with Home Health Agency 1 (HHA 1). The PDPOCS indicated a section for each interdisciplinary team (IDT - a group of dedicated healthcare professionals who work to bring knowledge together to help residents receive the care they need) that included rehabilitation services, dietary services, social services, activities services and nursing services. Each section of the IDT team included notes of discharge recommendations, in which these sections were blank and did not have any information. The PDPOCS IDT sections were all signed and documented by Licensed Vocational Nurse 2 (LVN 2).During a review of Resident 1's Notice of Proposed Transfer/Discharge indicated the notification was sent to Ombudsman via facsimile transmission dated 8/27/2025.During a review of HHA medical record, titled, Start of Care dated 8/27/2025, it was indicated that Resident 1's home environment was altered with cluttered/soiled living conditions, difficulty buying necessities, lack of caregiver/family support, limited social contact and has poor home environment. The Start of Care also indicated that, Patient (Resident 1) has three cats in her home, home is littered with cat urine and feces. Patient (Resident 1) has a POA who lives one hour away and does not visit frequently. It was suggested to patient (Resident 1) to go to assisted living or low-income housing, patient (Resident 1) stated she doesn't want anyone to pull her out of home, she (Resident 1) wants to pass away in the same home her husband passed away in. Patient (Resident 1) with a left above knee amputation exhibits significant mobility limitations and environmental safety risks. Patient (Resident 1) has difficulty independently propelling her WC and demonstrates limited mobility within the home. The living environment is noted to be unclean, with spider webs, excessive dust, and foul odor. Bed [NAME] is high, creating additional fall risk for an amputee. Multiple arcade machines present further clutter and obstruct safe wheelchair navigation.During an interview with Certified Nursing Assistant 1 (CNA 1) on 9/3/2025 at 12:04 p.m., CNA 1 stated, Resident 1 needs assistance with toileting, showering and transferring from bed to a 555054 Page 2 of 5 555054 09/05/2025 Pacific Post Acute 1323 17th Street Santa Monica, CA 90404

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wheelchair while in the facility. CNA 1 stated, Resident 1 was unable to feel if her incontinent brief was wet as she would verbalize to CNA 1 that it wasn't time for her to be changed but when she checked her incontinent brief, it would be wet.During an interview with Physical Therapist Assistant 1 (PTA 1) on 9/3/2025 at 12:25 p.m., PTA 1 stated that Resident 1 had a non-weight bearing order by the physician on her left lower extremity due to a recent revision of above the knee amputation. PTA 1 stated, during PT exercises, Resident 1 required assistance with transferring from bed to wheelchair and unmotivated during therapy with feeling down. PTA 1 stated, Resident 1's physical therapy goal was to be able to use prosthetic so she may move independently and be functional with ADLs. PTA 1 stated, they could not use her prosthetic as they have not received a clearance from her physician, and her left lower extremity and skin integrity was still recovering from her recent surgery. PTA 1 further stated, Resident 1 did not meet her goal for discharge planning.During an interview with EC 1 on 9/3/2025 at 2:54 p.m., EC 1 stated, he is Resident 1's POA per her (Resident 1)'s request. EC 1 stated, he had a different phone number that was listed on Resident 1's record. EC 1 stated, he was not included in the IDT meeting regarding Resident 1's discharge planning. EC 1 stated, he finally received a call from SSD on the day of Resident 1's discharge on [DATE] in which SSD informed him that Resident 1's was about to be picked up by the transportation to be discharged home and to make sure that he will be in Resident 1's home when she gets dropped off. EC 1 asked SSD why she (Resident 1) was being discharged , as he believed that Resident 1 will not be safe to be discharged home alone. EC 1 rushed to go to Resident 1's home on 8/26/2025 to help her when she gets home but he also left that night. EC 1 stated, he does not live with Resident 1 and Resident 1's home was neglected as no one lived in that house for months and it needs to be fixed and cleaned as her house was being housed by cats and racoons that were able to go in and out of the house due to a broken screen door. EC 1 further stated, Resident 1 does not have any mobile phone or any other phone that she may be contacted. EC 1 stated, HHA 1 contacted him as he was the only contact for Resident 1, so he decided to get Resident 1 a mobile phone so that she could be contacted. EC 1 stated, he visited Resident 1, along with his son on 9/1/2025 to give her mobile phone and that was when they found Resident 1 on the floor on her side, there were bowel movements on the floor, on the blanket and on certain parts of her body and she was unable to move on her own.During a concurrent interview with the Social Services Director (SSD) on 9/3/2025 at 1:07 p.m., SSD stated, she had sent in an application for home maker service, personal care and in-home care as part of her discharge planning during her initial admission but had not received any approval information. SSD stated that she was not aware that Resident 1 had a POA. SSD stated, Resident 1 verbalized of wanting to be discharged home on 8/21/2025 and wanted to leave against medical advice (AMA) so she contacted the physician to get an order for a HH and a WC. SSD stated, she was able to arrange a HH and Resident 1 agreed to stay until she was discharged on 8/26/2025. SSD stated, she tried contacting Resident 1's EC 1 on 8/21/2025 but she was unable to contact EC 1 because the contact information they had on file was a non-working number. SSD further stated, Resident 1 does not have a personal mobile phone and was aware there was no other personal contact when Resident 1 was discharged to home on 8/26/2025.During an interview with Home Health Agency Manager (HHAM) on 9/3/2025 at 1:44 p.m., HHAM stated, Resident 1 was initially evaluated by HHA nurse on 8/27/2025. HHAM stated Resident 1 does not have any mobile phone or any other form of communication, so the HHA nurse waited outside Resident 1's door for 30 minutes until Resident 1's opened the door. HHAM stated, on 8/28/2025, the Physical Therapist from HHA attempted to do their initial evaluation but Resident 1 did not open the door, and they were not able to talk to Resident 1. HHAM stated, he talked to Resident 1's EC 1 in which he recommended Resident 1 to have her own 555054 Page 3 of 5 555054 09/05/2025 Pacific Post Acute 1323 17th Street Santa Monica, CA 90404

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few mobile phone so they can contact her. HHAM stated, no other visit was conducted with Resident 1 after 8/27/2025.During an interview LVN 2 on 9/3/2025 at 2:21 p.m., LVN 2 stated, he documented and signed Resident 1's PDPOCS upon discharge on [DATE]. LVN 2 stated, he did not do the discharge teaching and education for Resident 1, and he just documented all IDT sections and signed it so it would be completed. LVN 2 stated, he left the form blank for each IDT services and recommendations because he doesn't know what Resident 1 status upon discharged .During a follow-up interview with SSD on 9/5/2025 at 1:37 p.m., SSD stated, during the initial IDT meeting, Resident 1 verbalized that she wanted to go home during discharge planning. SSD stated, when she asked for a discharge order from the physician, she did not ask the nursing team and rehabilitation team regarding Resident 1's needs for a safe discharge and she thought a home health agency would be able to provide her needs upon discharging to home. SSD stated that she was aware that Resident 1 was not able to use her prosthetic for three months, as ordered by her surgeon, so that her skin will heal after her surgery. SSD stated, she did not talk to Resident 1's EC 1 during her stay in the facility and was not aware of Resident 1's living situation at home with SSD verbalizing, how am I supposed to know those things?.During an interview with Director of Nursing (DON) on 9/5/2025 at 1:52 p.m., DON stated, Resident 1 wanted to go home but she needs a 24-hour care to be safe at home. DON Stated she had not seen EC 1 visit the facility and was not aware that he was given instructions on how to care for Resident 1 upon discharge as a care giver. DON stated, it is up to the nursing department and the whole IDT to determine if Resident 1 can be discharged to home safely, it is not just the decision of the social services department. DON stated, if Resident 1 wanted to go AMA, they cannot stop or refuse but they can refer them to Adult Protective Services (APS - a state-run program that protects vulnerable adults from abuse, neglect, and exploitation) so they may assess resident's home to ensure she will be safe at home. DON stated, APS was not contacted upon Resident 1's discharge to home. DON further stated, the post-discharge summary should be completed by documenting and signing each section by that particular IDT.During an interview with General Acute Care Hospital Social Worker 1 (GACH SW1) on 9/8/2025 at 2:04 p.m., GACH SW 1 stated, Resident 1 was admitted to GACH 2 with an initial diagnosis of ST-elevation myocardial infarction (STEMI - is a type of heart attack that is more serious and has a greater risk of serious complications and death). GACH SW 1 stated, Resident 1 was found on the floor with extensive wound on her right forehead, right elbow, right heel, right hip thigh, right shoulder and the wound on her right shoulder was horrible. GACH SW 1 stated, POA questioned the facility why Resident 1 was being discharged home without proper care and without confirming with him. During a review of the facility's policy and procedure (P&P), titled, Discharge Planning Process, date reviewed/revised by facility on 5/28/2025, the P&P indicated, It is the policy of this facility to develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmission.In cases where the resident wishes to be discharged to a setting that does not appear to meet his or her post-discharge needs, or appears unsafe, the IDT will treat this situation similarly to refusal of care: discussed with the resident, (and/or his of her representative, if applicable) and document the implications and/or risks of being discharged to a location that is not equipped to meet his/her needs and attempt to ascertain why the resident is choosing that location; offer other, more suitable, options of locations that are equipped to meet the needs of the resident. Document any discussions related to the options presented; Document refusals of other options that could meet the resident's needs; At time of discharge, follow policies regarding discharges Against Medical Advice, and refer to Adult Protective 555054 Page 4 of 5 555054 09/05/2025 Pacific Post Acute 1323 17th Street Santa Monica, CA 90404

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Services (or other state entity charged with investigation abuse and neglect,) as necessary. If discharge to community is a goal, an active discharge care plan will be implemented and will involve the IDT, including the resident and/or resident representative. The plan shall be documented. The facility will document any referrals to local contact agencies or other appropriate entities made for the purpose of the resident's interest in returning to the community. The evaluation of the resident's discharge needs and discharge plan will be completely documented on a timely basis in the clinical record. The results of the evaluation and the final discharge plan will be discussed with the resident or resident's representative. Education needs, as identified in the discharge plan, will be provided to the resident and/or family member prior to discharge. 555054 Page 5 of 5