Health inspection·November 15, 2024

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, and per facility policy and procedures (P&P) titled Bed-Holds and Returns reviewed 1/2024, the facility failed to inform in writing one of four sampled residents (Resident 1) of the bed-hold and return policy when the resident was transferred to General Acute Care Hospital 1 (GACH 1) on 8/13/2024. This deficient practice had a potential to result in the resident's responsible party being unaware of the bed hold policy and can lead to a transfer of the resident to another skilled nursing facility not of the resident's or responsible party's preference. Findings: A review of Resident 1's admission Record indicated resident was admitted to the facility on [DATE] with diagnoses including hypertensive heart disease (a group of heart conditions caused by chronic high blood pressure), emphysema (lung condition that causes shortness of breath) and dysphagia (difficulty swallowing). A review of the Minimum Data Set (MDS - resident assessment tool) dated 7/13/2024, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was severely impaired. The MDS indicated Resident 1 required moderate assistance 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). A review of Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 8/13/2024 indicated the physician recommended to send Resident 1 to GACH 1 due to low blood oxygen level. A review of Resident 1's Physician Order Summary and electronic and paper medical chart as of 11/15/2024, indicated there was no order for Bed-hold and no Bed-hold notice completed after Resident 1 was hospitalized on [DATE]. During an interview with the Director of Nursing (DON) on 11/15/2024 at 3:06 p.m., the DON stated there was no physician order for Resident 1's bed-hold and there was no Bed-hold notice completed after Resident 1's hospitalization. The DON stated there should have been a notification of Bed-hold and documentation if bed-hold was offered to Resident 1 ' s responsible party. A review of the facility's policy and procedure (P&P) titled, Bed-Holds and Returns, reviewed Page 1 of 6 555748 555748 11/15/2024 Berkley East Healthcare Center 2021 Arizona Ave Santa Monica, CA 90404

F 0625 Level of Harm - Minimal harm or potential for actual harm 1/2024, the P&P indicated, Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy . Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail: a. The rights and limitations of the resident regarding bed-holds; Residents Affected - Few b. The reserve bed payment policy as indicated by the state plan (Medicaid residents); c. The facility per diem rate required to hold a bed (non-Medicaid residents), or to hold a bed beyond the state bed-hold period (Medicaid residents); and d. The details of the transfer (per the Notice of Transfer). 555748 Page 2 of 6 555748 11/15/2024 Berkley East Healthcare Center 2021 Arizona Ave Santa Monica, CA 90404

F 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to readmit one of four sampled residents (Resident 1) to the facility following hospitalization at General Acute Care Hospital 1 (GACH 1) on 8/13/2024 according to the facility's policy and procedure (P&P) titled, Transfer or Discharge, Facility-initiated. As a result, Resident 1 remained in GACH 1 and had the potential to cause psychosocial harm. Findings: A review of Resident 1's admission Record indicated resident was admitted to the facility on [DATE] with diagnoses including hypertensive heart disease (a group of heart conditions caused by chronic high blood pressure), emphysema (lung condition that causes shortness of breath) and dysphagia (difficulty swallowing). A review of the Minimum Data Set (MDS - resident assessment tool) dated 7/13/2024, indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was severely impaired. The MDS indicated Resident 1 required moderate assistance 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). A review of Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 8/13/2024 indicated the physician recommended to send Resident 1 to GACH 1 due to low blood oxygen level. A review of Resident 1's GACH1 referral sent to the facility on 8/19/2024, indicated, Resident 1 was to be discharged from the hospital after 8/19/2024. During an interview with Business Development (BD) on 11/14/2024 at 1:57 p.m., BD stated, they received GACH 1 ' s referral for Resident 1 on 8/19/2024 for readmission after hospitalization. BD stated the referral was sent to clinical staff to review in which the referral was to be approved by the clinical staff before the facility could readmit resident. BD stated the referral was reviewed by the Director of Nursing (DON) and the Administrator (ADM). BD stated, upon review by the clinical staff, BD was notified the facility was unable to readmit Resident 1 because the facility was unable to accommodate Resident 1 ' s needs. During an interview with the Director of Nursing (DON) on 11/15/2024 at 3:06 p.m., the DON stated the facility was not able to accommodate Resident 1 ' s needs which was why the facility did not readmit Resident 1 after hospitalization from GACH 1. The DON stated, Resident 1's family member (FM) tended to refuse care which could end with Resident 1 requiring transfer back to the hospital. The DON reviewed GACH 1 ' s referral with surveyor and stated, the facility was able to clinically meet the Resident 1 ' s post-hospitalization care plan but the DON was not aware of the GACH ' s referral. When asked if facility provided a reasonable and appropriate notice and documentation why the facility was unable to accommodate Resident 1 after hospitalization, DON stated, no. A review of the facility's P&P titled, Transfer or Discharge, Facility-Initiated, reviewed 1/2024, the P&P indicated, Residents who are sent emergently to an acute care setting, such as a hospital, 555748 Page 3 of 6 555748 11/15/2024 Berkley East Healthcare Center 2021 Arizona Ave Santa Monica, CA 90404

F 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few are permitted to return to the facility. Residents who are sent to the acute care setting for routine treatment/planned procedures are also allowed to return to the facility . If the facility does not permit a resident's return to the facility (i.e., initiates a discharge) based on inability to meet the resident's needs, the facility will notify the resident, and/or his or her representative in writing of the discharge, including notification of appeal rights . If the facility determines that the resident cannot return to the facility, the medical record will indicate that the facility made efforts to: a. determine if the resident still requires the services of the facility and is eligible for Medicare skilled nursing facility or Medicaid nursing facility services; b. ascertain an accurate status of the resident's condition, which can be accomplished via communication between hospital and facility staff and/or through visits by facility staff to the hospital. 555748 Page 4 of 6 555748 11/15/2024 Berkley East Healthcare Center 2021 Arizona Ave Santa Monica, CA 90404

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to revise a care plan for weight loss for two of four sampled residents (Resident 1 and 2), who had actual significant weight loss. This deficient practice had the potential to place Resident 1 and 2 at risk for recurrent weight loss. Findings: 1. A review of Resident 1's admission Record indicated resident was admitted to the facility on [DATE] with diagnoses including hypertensive heart disease (a group of heart conditions caused by chronic high blood pressure), emphysema (lung condition that causes shortness of breath) and dysphagia (difficulty swallowing). A review of the Minimum Data Set (MDS - resident assessment tool) dated 7/13/2024, indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was severely impaired. The MDS indicated Resident 1 required moderate assistance from staffs for Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). A review of Resident 1's weight indicated the following: i. 7/15/2024: 107 pounds (lbs. - unit of measurement) ii. 8/1/2024: 101 lbs. iii. 8/5/2024: 100 lbs. A review of Resident 1's care plan (CP) initiated on 7/10/2024 for residents at risk of weight loss related to meal intake less than 50 percent (% - unit of measurement), indicated a goal of Resident will show evidence of good hydration. The care plan indicated no revisions were made since the initiation date of 7/10/2024. A review of Resident 1's Progress Notes by Registered Dietitian (RD) on 8/2/2024, indicated Resident 1 had a significant weight loss of 5.6% within three weeks . Resident 1 is not eating well . may benefit from appetite stimulant. 2. A review of Resident 2's admission Record indicated resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), Type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and dysphagia. A review of the MDS dated [DATE], indicated Resident 2's skills for daily decisions was moderately impaired. The MDS indicated Resident 1 required moderate assistance from staffs for ADLs. A review of Resident 2's weight indicated the following: 555748 Page 5 of 6 555748 11/15/2024 Berkley East Healthcare Center 2021 Arizona Ave Santa Monica, CA 90404

F 0657 i. 7/10/2024: 132 lbs. Level of Harm - Minimal harm or potential for actual harm ii. 8/5/2024: 127 lbs. iii. 8/19/2024: 121 lbs. Residents Affected - Few A review of Resident 2's CP initiated on 7/10/2024 for resident's impaired nutritional and hydration status, indicated a goal of Resident will show evidence of good hydration. The care plan indicated no revisions were made since the initiation date of 7/10/2024. A review of Resident 2's Progress Notes by RD on 8/19/2024, indicated Resident 2 had a significant weight loss of 10.4% within one month . Resident 2 with significant weight loss likely related to very poor intake . suggested to start an appetite stimulant. During an interview with the Registered Dietitian (RD) on 11/15/2024 at 12:45 p.m., the RD stated Resident 1 had a significant weight loss of 5.6% within three weeks in which the RD recommended adding an appetite stimulant. The RD stated Resident 2 also had a significant weight loss of 10.4% within a month. The RD stated she did not revise the current CP of at risk for weight loss and impaired nutritional status for Resident 1 and Resident 2. The RD stated that was the nursing staff ' s responsibility to revise and update the CP ' s and told surveyor to question the nursing staff. During an interview with the Director of Nursing (DON) on 11/15/2024 at 2:47 p.m., the DON stated any licensed staff could revise and initiate a CP. The DON stated since the RD's responsibilities were to recommend plan of care when a resident had a significant weight loss, it was the RD's responsibilities to revise and initiate a CP. The DON stated, a CP should have been revised for the actual weight loss of Residents 1 and 2 so that the nursing staff would do interventions that were recommended and suggested by the RD. During a review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention, revised 1/2024, the P&P indicated, The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss = {usual weight - actual weight) I (usual weight) x 100]: a. I month - 5% weight loss is significant; greater than 5% is severe . Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietitian, the Consultant Pharmacist, and the resident or resident's legal surrogate. 555748 Page 6 of 6