Health inspection·December 19, 2024

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to protect and safeguard the residents personal and medical records according to the facility's policy and procedures (P&P), titled, confidentiality of information and personal privacy, reviewed 1/2024 for 11 of 13 sampled residents (Residents 11, 31, 44, 59, 65, 78, 142, 242, 343, 345, and 346). Residents Affected - Some This deficient practice violated the resident's rights for privacy. Findings: A review of Resident 11's admission Record indicated the facility admitted Resident 11 on 11/17/2024 with diagnoses including atrial fibrillation (a heart condition where the upper chambers of the heart beat irregularly and rapid causing racing sensation), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (a mental health condition that causes a person to experiences excessive and intense feelings of fear, worry, dread, and uneasiness). A review of Resident 31's admission Record indicated the facility admitted Resident 31 on 12/18/2019 and readmitted Resident 31 on 3/5/2024 with diagnoses including end stage renal disease (ESRD - irreversible kidney failure), diabetes mellitus (DM -a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypothyroidism (a condition where the thyroid gland doesn't produce enough thyroid hormone). A review of Resident 44's admission Record indicated the facility admitted Resident 44 on 9/2/2024 with diagnoses including hypothyroidism (a condition where the thyroid gland doesn't produce enough thyroid hormone), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (a mental health condition that causes a person to experiences excessive and intense feelings of fear, worry, dread, and uneasiness). A review of Resident 59's admission Record indicated the facility admitted Resident 59 on 9/9/2023 and readmitted Resident 59 on 11/15/2024 with diagnoses including diabetes mellitus (DM -a disorder characterized by difficulty in blood sugar control and poor wound healing), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (a mental health condition that causes a person to experiences excessive and intense feelings of fear, worry, dread, and uneasiness). A review of Resident 65's admission Record indicated the facility admitted Resident 65 on 3/1/2024 with diagnoses including hypothyroidism (a condition where the thyroid gland doesn't produce enough thyroid hormone), insomnia (a common sleep disorder that makes it difficult to fall or stay asleep, Page 1 of 19 555748 555748 12/19/2024 Berkley East Healthcare Center 2021 Arizona Ave Santa Monica, CA 90404

F 0583 or get to quality sleep), and history of falling. Level of Harm - Minimal harm or potential for actual harm A review of Resident 78's admission Record indicated the facility admitted Resident 78 on 11/7/2024 with diagnoses including metabolic encephalopathy (imbalance in the body's chemical causing the brain not to work properly), atrial fibrillation (a heart condition where the upper chambers of the heartbeat irregularly and rapid causing racing sensation), and acute kidney failure (kidneys suddenly stop working properly). Residents Affected - Some A review of Resident 142's admission Record indicated the facility admitted Resident 142 on 12/12/2024 with diagnoses including hypertension (HTN -high blood pressure), chronic obstructive pulmonary disease (COPD -a chronic lung disease causing difficulty in breathing), and bronchiectasis (a chronic lung condition that occurs when the airway in the lungs become damaged, widened, and scarred). A review of Resident 242's admission Record indicated the facility admitted Resident 242 on 8/28/2024 and readmitted Resident 242 on 12/14/2024 with diagnoses including diabetes mellitus (DM -a disorder characterized by difficulty in blood sugar control and poor wound healing), depression (a mental health condition that involves a persistent low mood and loss of interest in activities that a person normally enjoys), and anxiety disorder (a mental health condition that causes a person to experience excessive and intense feelings of fear, worry, dread, and uneasiness). A review of Resident 343's admission Record indicated the facility admitted Resident 343 on 12/10/2024 with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), anxiety disorder (a mental health condition that causes a person to experience excessive and intense feelings of fear, worry, dread, and uneasiness), and chronic kidney disease (CKD -gradual damage to the kidneys so they cannot filter waste from the blood properly causing a buildup of toxins in the body). A review of Resident 345's admission Record indicated the facility admitted Resident 345 on 12/9/2024 with diagnoses including hypertension (HTN -high blood pressure), depression (a mental health condition that involves a persistent low mood and loss of interest in activities that a person normally enjoys), and history of falling. A review of Resident 346's admission Record indicated the facility admitted Resident 346 on 12/3/2024 with diagnoses including depression (a mental health condition that involves a persistent low mood and loss of interest in activities that a person normally enjoys), hypertension (HTN -high blood pressure), and history of falling. During an initial tour of the facility on 12/16/2024, at 10:10 A.M., Resident 141's family member (FM) approached surveyor with a stack of documents and stated, I found these documents in Resident 141's room, I think they are all medical records and they do not belong to Resident 141. During a concurrent interview and record review of the documents found in Resident 141's room, on 12/16/2024, at 10:12 A.M., with the Social Services Director (SSD), the SSD was within an ear shot of the conversation that this surveyor had with Resident 141's FM, SSD confirmed that the records that were found by Resident 141's FM were other residents medical records and that they should have not been in Resident 141's room for confidentiality reasons and that it was a violation on Health Insurance Portability and Accountability Act (HIPAA - federal standards protecting sensitive health information from disclosure without patient's consent). 555748 Page 2 of 19 555748 12/19/2024 Berkley East Healthcare Center 2021 Arizona Ave Santa Monica, CA 90404

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 12/19/2024, at 10:06 A.M., with the Case Manager (CM), the CM stated the documents found in Resident 141's room were his and that those documents belonged to other residents and not Resident 141. The CM stated the documents included but were not limited to other residents' information from the hospital, resident demographics, resident financial information, residents' insurance information, residents' clinical information and residents living information, overall, a brief summary of their (residents) house and personal information. CM stated residents' medial information should not be in the residents' rooms due to HIPAA, medical records should not be accessible to other residents or their responsible party. The CM states exposure of the residents' medical records to unauthorized individuals will cause residents to feel unsafe, due to the invasion of their privacy and lead to other individuals discussing their (residents) personal information. During an interview 0n 12/19/2024, at 9:57 A.M., with the Facility Administrator (FA), the FA stated residents' medical information should not be in other residents' room, it is a violation of HIPAA. The FA stated the facility has already reported the incident to their HIPAA compliance officer and a case was opened. A review of the facility's P&P, titled, Confidentiality of Information and Personal Privacy, revised 1/20214, indicated Policy Statement: Our facility will protect and safeguard resident confidentiality and personal privacy . 1. The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. 2. The facility will strive to protect the resident's privacy regarding his or her: a. Medical treatment; 3 4. Access to resident personal and medical records will be limited to authorized staff and business associates. 555748 Page 3 of 19 555748 12/19/2024 Berkley East Healthcare Center 2021 Arizona Ave Santa Monica, CA 90404

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, and record review, the facility failed to label Resident 141's enteral feeding (aka tube feeding - the delivery of nutrients through a feeding tube directly into the stomach) for one of 22 sampled residents. This deficient practice had the potential to cause complications associated with enteral feeding, including infection. Findings: A review of Resident 141's admission Record indicated the facility admitted the resident on 12/2/2024 with diagnoses including tongue cancer, dysphagia (difficulty swallowing) and endocarditis (inflammation of (inflammation of cardiac tissue, usually caused by a bacterial infection. A review of Resident 141's Minimum Data Set (MDS- a resident assessment tool) dated 12/6/2024 indicated the resident's cognition was severely impaired. The MDS also indicated Resident 131 was totally dependent upon staff oral hygiene, bathing, dressing, toileting and personal hygiene. The MDS further indicated the resident had a feeding tube. A review of Resident 141's Physician Orders dated 12/4/2024 indicated every shift administer Glucerna 1.5 (specific type of tube feeding formula for people with diabetes) via gastrostomy tube (GT - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) at 65 milliliters per hour (mL/hr, a unit of measurement for rates of administration) [for] 20 [hours] via enteral pump (a pump that administers TF at a controlled rate) to provide 1949 kcal (a unit of measurement and another word for what's commonly called a calorie). Start administration at 2 pm to 10 am or until dose is completed. A review of Resident 141's at risk care plan titled, initiated 12/3/2024 indicated the resident required a feeding tube due to malnutrition. The care plan also indicated the resident was at risk for aspiration, ostomy site infection and significant weight changes. The care plan interventions indicated staff were to administer the prescribed tube feeding, change tubing every 24 hours and observe and notify the physician for signs and symptoms of infection at the insertion site and surround skin areas. During an observation on 12/16/2024 at 8:46 AM at Resident 141's bedside, Resident 141's enteral feeding was observed. The enteral feeding was running, the bottle was not labeled. During a concurrent interview and observation on 12/16/2024 at 8:58 AM with Licensed Vocational Nuse 1 (LVN 1) at Resident 141's bedside, Resident 141's enteral feeding ws observed. LVN 1 stated Resident 1's enteral feeding bottle was not labeled. LVN 1 stated he was not able to say when the bottle was first administered. LVN 1 further stated staff were to label the bottle with the resident name, time, date of administration. LVN 1 stated this is an infection control issue. During an interview on 12/19/2024 at 11:01 AM, the Director of Nursing (DON) stated the enteral feeding is labeled with the resident's name, room number, feeding rate every time the bottle is changed. The DON further stated the enteral feeding is labeled to confirm the correct administration and for infection control. 555748 Page 4 of 19 555748 12/19/2024 Berkley East Healthcare Center 2021 Arizona Ave Santa Monica, CA 90404

F 0693 A review of the facility's policy and procedures titled, Enteral Nutrition, revised 11/2018, indicated the Nurse confirms that orders for enteral nutrition are complete. Complete orders include: Level of Harm - Minimal harm or potential for actual harm a. The enteral nutrition product; Residents Affected - Few b. Delivery site (tip placement); c. The specific enteral access device (nasogastric, gastric, jejunostomy tube, etc.; d. Administration method ( continuous, bolus, intermittent); e. Volume and rate of administration; f. The volume/rate goals and recommendations for advancement toward these; and g. Instructions for flushing (solution, volume, frequency, timing and 24-hour volume). 555748 Page 5 of 19 555748 12/19/2024 Berkley East Healthcare Center 2021 Arizona Ave Santa Monica, CA 90404

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to obtain a physician's order for the use of Continuous Positive Airway Pressure (machine helps treat sleep apnea [a sleep disorder that causes breathing to repeatedly stop and start during sleep]. CPAP machine delivers continuous air through your mouth and/or nose to keep your airways)/Bilevel Positive Airway Pressure (BIPAP a noninvasive breathing device that helps people who have trouble breathing) upon admission for one of six sampled residents, Resident 191. Residents Affected - Few This deficient practice had the potential to place Resident 191 at risk for respiratory distress and death. Findings: A review of Resident 191's admission Record indicated the facility admitted Resident 191 on 15/15/2024 with a diagnosis that included obstructive sleep apnea and polyneuropathy (a condition that occurs when many peripheral nerves in the body malfunction at the same time). A review of Resident 191's Information record dated 12/15/2024, indicated Resident 191 has a diagnosis of sleep apnea (CPAP at night). A review of Resident 191's admission Physician Orders dated 12/15/24, indicated there was no physician orders for the use of CPAP at night on the day of admission. A review of Resident 191's physician orders dated 12/17/2024, indicated a physician order for the use of CPAP. A review of Resident 191's care plan titled, :Needs Special Care related to CPAP/BIPAP machine use:, initiated on 12/16/2024, included the following interventions: Monitor resident for episodes of shortness of breath, CPAP/BIPAP (pre-settings as ordered by MD, CPAP Setting: 9cmH20 (centimeters of water-unit of measurement) at bedtime CPAP:9cmH20 and remove per schedule A review of Resident 191's Progress Notes dated 12/19/2024, indicated Resident 191 has the capacity to understand and make decisions. During an interview on 12/18/24 at 8:03 am, Registered Nurse 1 (RN1) stated she has been employed with the facility for 8 months. RN 1 stated she has not had any training on how to use a CPAP/BIPAP from the staff at the facility. RN1 stated if a nurse is not knowledgeable on how to efficiently use a CPAP/BIPAP a resident could go into respiratory distress and die. During an interview on 12/18/24 at 8:23 am, License Vocational Nurse (LVN) 1 stated he has been employed with the facility for 1 year. LVN 1 stated he has not had any training on how to use a CPAP/BIPAP machine. During an interview on 12/18/24 at 8:23 am, LVN 2 stated she has been employed with the facility for 4 months and has not had any training on how to use a CPAP/BIPAP at the facility. During a concurrent on 12/18/24 at 10:24 am, record review of the employee files for LVN 1, LVN 2, and RN 1, there was no annual skills competency check list, or in-service training on how to use a 555748 Page 6 of 19 555748 12/19/2024 Berkley East Healthcare Center 2021 Arizona Ave Santa Monica, CA 90404

F 0695 CPAP/BIPAP machine. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/18/24 at 10:33 am, Director of Staff Development (DSD) stated she has been employed with the facility for 1 month. DSD stated it is important for the nursing staff to be knowledgeable in the use of a CPAP/BIPAP so that the nurses will know the signs and symptoms of respiratory distress, malfunction of the BIPAP, and how to troubleshoot the CPAP/BIPAP if it is not functioning properly. DSD stated she has not had a chance to conduct an in-service on CPAP/BIPAP for the residents. Residents Affected - Few During an interview on 12/18/24 at10:58 am, the Director of Nursing (DON) stated if the staff is not trained properly the resident could have increased Carbon Dioxide (C02 colorless, odorless gas that is naturally present in the air, produced when we breathe out), go into respiratory distress, and stop breathing. DON stated the previous DSD conducted an in-service on the use of a BIPAP, but he does not have a copy of the in-service. A review of the facility policy and procedures titled CPAP/BIPAP Support with a revised date of 1/2024, indicated : Purpose: 1. To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen. 2. To improve arterial oxygen (Pao2) in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease. 3. To promote resident comfort and safety. 555748 Page 7 of 19 555748 12/19/2024 Berkley East Healthcare Center 2021 Arizona Ave Santa Monica, CA 90404

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure that a hemodialysis (HD -a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) emergency kit was at the bedside for one of ten sampled residents (Resident 26). Residents Affected - Few This deficient practice had the potential to delay life saving interventions during accidental bleeding. Findings: A review of Resident 26's admission Record indicated the facility admitted Resident 26 on 5/3/2024 and readmitted Resident 26 on 11/29/2024 with diagnoses including end stage renal disease (ESRD irreversible kidney failure), metabolic encephalopathy (a disease or disorder that affects the structure or function of the brain), and generalized muscle weakness (feeling weak or lacking strength in most of the muscles throughout the body). A review of Resident 26's Minimum Data Set (MDS - a resident assessment tool) dated 12/3/2024, indicated Resident 26 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 44 was dependent on staff for activities of daily living. During a concurrent observation and interview on 12/16/2024, at 10:49 A.M., with Licensed Vocational Nurse 1 (LVN 1), there was no HD emergency kit at the bedside, LVN 1 stated, Resident 26 has HD on Mondays, Wednesday, and Fridays. LVN 1 stated Resident 26 does not have a HD emergency kit at the bedside because we no longer keep them (HD emergency kit) at the bedside because family members take them (HD emergency kit) home. LVN 1 stated a HD emergency kit at the bedside is needed in case of an emergency or complication such as bleeding. It (HD emergency kit) is at the bedside to control bleeding, and if the kit is not at the bedside resident may bleed to death. During an interview on 12/19/2024, at 9:29 A.M., with the Director of Nursing (DON), the DON stated HD kit should be at the bedside for easy reach in case of any emergency bleeding to help stop the bleeding promptly. The DON stated potential adverse outcome of not having the HD emergency kit at the bedside is that the resident may have bleeding which can lead to hypovolemic shock. Having the HD kit the bedside can alleviate adverse outcomes because time is of the essence. A review of the facility's policy and procedures titled, End-Stage Renal Disease, Care of a Resident with reviewed 1/2024, indicated, Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care . h. Provision of an emergency kit at bedside and on the crash carts. 555748 Page 8 of 19 555748 12/19/2024 Berkley East Healthcare Center 2021 Arizona Ave Santa Monica, CA 90404

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on interview and record review failed to: 1. Ensure staff was competent on how to use a Continuous Positive Airway Pressure (machine helps treat sleep apnea [a sleep disorder that causes breathing to repeatedly stop and start during sleep]. CPAP machine delivers continuous air through your mouth and/or nose to keep your airways)/Bilevel Positive Airway Pressure (BIPAP a noninvasive breathing device that helps people who have trouble breathing) . 2. Ensure staff completed their annual skills competencies. These failures can cause or have the potential to cause a resident to go into respiratory distress. Findings: A review of Resident 191's admission Record indicated the facility admitted Resident 191 on 15/15/2024 with a diagnosis that included obstructive sleep apnea and polyneuropathy (a condition that occurs when many peripheral nerves in the body malfunction at the same time). A review of Resident 191's Information record dated 12/15/2024, indicated Resident 191 has a diagnosis of sleep apnea (CPAP at night). A review of Resident 191's admission Physician Orders dated 12/15/24, indicated there was no physician orders for the use of CPAP at night on the day of admission. A review of Resident 191's physician orders dated 12/17/2024, indicated a physician order for the use of CPAP. A review of Resident 191's care plan titled, :Needs Special Care related to CPAP/BIPAP machine use:, initiated on 12/16/2024, included the following interventions: Monitor resident for episodes of shortness of breath, CPAP/BIPAP (pre-settings as ordered by MD, CPAP Setting: 9cmH20 at bedtime CPAP:9cmH20 and remove per schedule During an interview on 12/18/24 at 8:03 am, Registered Nurse 1 (RN1) stated she has been employed with the facility for 8 months. RN 1 stated she has not had any training on how to use a CPAP/BIPAP from the staff at the facility. RN1 stated if a nurse is not knowledgeable on how to efficiently use a CPAP/BIPAP a resident could go into respiratory distress and die. During an interview on 12/18/24 at 8:23 am, License Vocational Nurse (LVN) 1 stated he has been employed with the facility for 1 year. LVN 1 stated he has not had any training on how to use a CPAP/BIPAP machine. During an interview on 12/18/24 at 8:23 am, LVN 2 stated she has been employed with the facility for 4 months and has not had any training on how to use a CPAP/BIPAP at the facility. LVN 2 stated she was trainied by a respiratory therapist at her previous job approximately 1 year ago. LVN 2 tated if the nurses are not properly trained on how to use a BIPAP the resident can go into respiratory 555748 Page 9 of 19 555748 12/19/2024 Berkley East Healthcare Center 2021 Arizona Ave Santa Monica, CA 90404

F 0726 distress and stop breathing. Level of Harm - Minimal harm or potential for actual harm During a concurrent on 12/18/24 at 10:24 am, record review of the employee files for LVN 1, Certified Nursing Asistant (CNA) 1, LVN 2, and RN 1, idicated there was no annual skills competency check list, or in-service training on how to use a BIPAP. Residents Affected - Few During an interview on 12/18/24 at 10:33 am, Director of Staff Development (DSD) stated she has been employed with the facility for 1 month. DSD stated it is important for the nursing staff to be knowledgeable in the use of a CPAP/BIPAP so that the nurses will know the signs and symptoms of respiratory distress, malfunction of the BIPAP, and how to troubleshoot the CPAP/BIPAP if it is not functioning properly. DSD stated she has not had a chance to conduct an in-service on CPAP/BIPAP for the residents. During an interview on 12/18/24 at10:58 am, the Director of Nursing (DON) stated if the staff is not trained properly the resident could have increased Carbon Dioxide (C02 colorless, odorless gas that is naturally present in the air, produced when we breathe out), go into respiratory distress, and stop breathing. DON stated the previous DSD conducted an in-service on the use of a CPAP/BIPAP, but he does not have a copy of the in-service. A review of the facility policy and procedures titled CPAP/BIPAP Support with a revised date of 1/2024, indicated: Preparation: 1.Only a qualified and properly trained nurse or respiratory therapist should administer oxygen through a CPAP mask. 555748 Page 10 of 19 555748 12/19/2024 Berkley East Healthcare Center 2021 Arizona Ave Santa Monica, CA 90404

F 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to: Residents Affected - Some 1. Ensure the facility received and reviewed daily activity and discrepancy reports of the Cubex system (a computerized system that stores, dispenses, and tracks medications in healthcare setting), which was inconsistent with the facility policy for at least 11 months. 2. Ensure non-controlled drug dispositions (the process of returning or destroying unused medications) were performed and recorded by two licensed nurses as per policy for at least 8 months. 3. Ensure outdated medication are discarded and not stored in a medication cart. These deficient practices had the potential for medication errors, loss and/or diversion (transfer of medication from a lawful to an unlawful channel of distribution or use) of medications, and the potential for residents to receive outdated, deteriorated, and ineffective medication. Findings: 1. During an observation on [DATE] at 11:50 AM in a medication room on the 2nd floor, and a concurrent interview with a Licensed Vocation Nurse (LVN 2). There was an automated drug dispensing cabinet (Cubex, a computerized system that stores, dispenses, and tracks medications in healthcare setting) inside the medication room. There was a binder labeled inventory count next to the Cubex which indicated the facility pharmacist consultant performed inventory count once a month. LVN 2 stated the facility used Cubex for resident's first dose for new order and/or as oral emergency drugs supply. During an interview on [DATE] at 12:45 PM, the director of nursing (DON) could not pull activity report from Cubex. DON contacted the Cubex specialist (CS) of the facility pharmacy who stated the facility did not have access to reports. CS stated activity/transaction/discrepancy reports were sent to the DON daily via email. During a concurrent interview, DON stated the pharmacy took care of discrepancies. DON did not recall reviewing any Cubex reports. A review of the facility's policy and procedures titled Resolving Discrepancies Automated Drug Delivery Systems (dated 5/2019) indicated . Transaction and . Controlled Medication Discrepancy Report shall be generated and reviewed daily by the Director of Nursing . During an interview on [DATE] at 2:45 PM, the Quality Assurance Nurse (QA) stated Cubex was installed in [DATE]. During an interview on [DATE] at 3:02 PM, DON called the facility pharmacy personnel who stated the daily activity or transaction report of the Cubex was automatically generated by the system and automatically emailed to the facility designated person. During an interview on [DATE] at 3:14 PM, DON searched the email record and stated they had not received any reports from the pharmacy since the facility started using Cubex in [DATE]. During an interview on [DATE] at 3:31 PM, DON confirmed the facility did not have access or ability 555748 Page 11 of 19 555748 12/19/2024 Berkley East Healthcare Center 2021 Arizona Ave Santa Monica, CA 90404

F 0755 Level of Harm - Minimal harm or potential for actual harm to generate reports from the Cubex. A moment later, the facility pharmacy emailed Cubex transaction occurred from September to November and from [DATE] to [DATE], to DON. During an interview on [DATE] at 9:40 AM, DON stated the facility pharmacy corrected the email address in the system and the facility received autogenerated email of the Cubex transaction report. Residents Affected - Some 2. During an interview on [DATE] at 10:01 AM, DON presented non-controlled med disposition log, dated [DATE]. DON stated there was 1 (one) nurse's signature on the log. During an interview on [DATE] at 2:22 PM, DON reviewed a binder of medication disposition records from February 2024 to [DATE], DON stated only the disposition record of [DATE] had 2 nurses' signatures. During a concurrent review of the facility policy, Medication Destruction (dated [DATE]), DON stated the medication disposition should be done in the presence of 2 nurses. 3. During an observation on [DATE] at 1:53 PM with LVN 2 at Nursing Station 1 of floor 2 Medication Cart 1, there were 2 boxes of fluticasone Propionate and Salmeterol inhalers (an inhalation medication to treat certain lung disease or chronic conditions) for Resident 8 During an interview on [DATE] at 1:58 PM, LVN 2 reviewed the aforementioned inhalers and confirmed one of those inhaler boxes had an open date of [DATE] written on the label and the other inhaler had an open date on [DATE]. LVN 2 reviewed the instruction on the inhaler box and stated, Discard after 1 month of opening. LVN 2 stated the inhaler with an open date of [DATE] had expired and would bring it to DON for disposal. During an interview on [DATE] at 2:35 PM, DON reviewed the aforementioned inhaler with an open date of [DATE] and stated the inhaler should have been removed from the medication cart when it became outdated on [DATE], since it was opened on [DATE]. A review of the facility's policy and procedures titled Discontinued Medications (dated 12/2018), indicated . If a medication expires, . drug container shall be marked . and shall be stored in a separate location designated solely for this purpose . 555748 Page 12 of 19 555748 12/19/2024 Berkley East Healthcare Center 2021 Arizona Ave Santa Monica, CA 90404

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to properly receive proper verificiation of informed consent (a principle in medical ethics and medical law that a patient should have sufficient information before making their own free decisions about their medical care) form prior to administering psychotropic medication Lexapro (an antidepressant medication) and Seroquel (an antipsychotic medication) for one of five sampled residents (Resident 77). This deficient practice had the potential for Resident 77 to receive medications without being properly informed of the medications' risks and adverse side effects that could lead to serious illness, hospitalization, or death. Findings: A review of Resident 77's admission Record indicated the resident was originally admitted to the facility on [DATE], and re-admitted on [DATE] with diagnoses that included but were not limited to encephalopathy (a disease damaged the functions of the brain) , sepsis (a very severe infection) and heart failure (condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen). A review of Resident 77's History and Physical, dated 11/7/2024 indicated the resident can make needs known but can not make medical decisions. A review of Resident 77's Minimum Data Set (MDS, a resident assessment tool), dated 12/3/2024, indicated the resident's cognitive skills of daily decisions making were severely impaired and required total assistance from staff with toileting hygiene, bathing and lower body dressing. A review of Resident 77's Physician's Orders, dated 11/29/2024, indicated Resident 77 to receive Lexapro 5 milligrams (mg-unit of measurement) by mouth once daily for depression manifested by self-isolation and withdrawn. A review of Resident 77's Physician's Orders, dated 11/30/2024, indicated Resident 77 to receive Seroquel 12.5 mg by mouth at bedtime for psychosis manifested by delirium until 12/5/2024. A review of Resident 77's Verification of Informed Consent for Psychotropic Medication, dated 11/29/2024, for Seroquel 12.5mg indicated facility verified informed consent with Resident 77. There was a section of the form where one could if the resident had or did not have the capacity to consent. This section was not filled out. A review of Resident 77's Verification of Informed Consent for Psychotropic Medication, dated 11/29/2024, for Lexapro 5mg, indicated facility verified informed consent with Resident 77. There was a section of the form where one could if the resident had or did not have the capacity to consent. This section was not filled out. A review of Resident 77's admission readmission Screen and Baseline Care Plan, dated 11/30/24 indicated the resident was confused. 555748 Page 13 of 19 555748 12/19/2024 Berkley East Healthcare Center 2021 Arizona Ave Santa Monica, CA 90404

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 77's Medication Administration Record (MAR) dated 12/2024, indicated the facility administered the medications Lexapro 5mg by mouth once daily from 12/1/2024 to 12/8/2024. The MAR also indicated the resident received Seroquel 12.5mg at bedtime from 12/1/2024 to 12/5/2024. During a concurrent interview and record review on 12/18/2024 at 12:55 PM, Resident 77's informed consents, dated 11/29/2024, for Seroquel and Lexapro were reviewed with Registered Nurse Supervisor 1 (RN 1). RN 1 stated staff are to verify with resident or resident's representative that informed consent was received. RN 1 stated the nurse verified informed consent was received from Resident 77. RN 1 further stated Resident 77 does not have capacity to make medical and the informed consent should have been received from the resident's representative and the informed consent form was executed incorrectly. RN 1 stated psychotropics can restrict the resident's behavior and cause them harm. During an interview on 12/19/2024 at 11:04 AM, the Director of Nursing (DON) stated the nurses validate with the family member or resident, if the resident has capacity that the MD got consent; Sometimes the resident changes their mind after the MD receives consent. The DON further stated informed consent ensures that we inform the RP/resident about the side effects, explain the risks and benefits and we want to make sure residents know the expected effects and adverse reactions that are possible. A review of the facility's undated policy and procedures titled, Informed Consent, dated 4/4/2024, indicated the licensed prescriber shall determine the capacity of the resident to understand and make decisions, if the resident is determined to not have the capacity to make informed decisions, a surrogate decision maker shall be identified. The licensed nurse shall verify from the resident and or legal representative where the consent has been obtained for the use of prescribed restraints and/or psychotropic medication, and will sign the form and document the name of the person who gave consent and the date when the consent was verified. 555748 Page 14 of 19 555748 12/19/2024 Berkley East Healthcare Center 2021 Arizona Ave Santa Monica, CA 90404

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, interview, and record review, the facility failed to ensure the label matched the correct quantity of a controlled medication (medications that the use and possession of are controlled by the federal government) received by the facility for a former resident. This deficient practice had the potential for loss or diversion (transfer of a controlled medication from a lawful to an unlawful channel of distribution or use) of controlled medications. Findings: During an observation on 12/18/24 at 1:53 PM at Nursing Station 1 on floor 2, and an inspection of the Medication Cart 1, there was a bundle of medications wrapped together by a rubber band in the locked compartment. Licensed Vocational Nurs2 (LVN) 2 stated that the aforementioned wrapped bundle were discontinued controlled medications to be brought to the director of nursing (DON) for disposition. During an observation on 12/18/24 at 2:11 PM, DON was in a meeting and instructed LVN 2 to hand off those discontinued controlled meds with the Registered Nurse (RN) 1. RN 1 stated the discontinued medications which would to be secured by DON for destruction later with the facility pharmacist. One of the aforementioned discontinued medications, was morphine sulfate (a potent opioid used in pain management) 100 milligrams (mg, an unit to measure mass) per (/) 5 milliliters (ml, an unit to measure volume) and the label indicated there was 15 ml in the bottle. The accountability record also indicated a qty (quantity) of 15 ml (milliliters-unit of measurement) and there was no indication of use. LVN 2 stated the bottle had not been opened. RN 1 stated the prints on the box and the bottle indicated there was 30 ml. During an interview on 12/18/24 at 2:28 PM the quality assurance nurse (QA) reviewed the aforementioned morphine sulfate container with DON. DON confirmed the quantity sent by the pharmacy did not match the label and the delivery receipt. QA stated this incident had a potential for diversion. A concurrent review of the delivery receipt faxed over by the pharmacy indicated the pharmacy delivered 15 ml on 12/12/2024. A review of the facility's policy and procedures (P&P) titled Ordering and Receiving Controlled Medications (April 2008), indicated . The director of nursing and the consultant pharmacist maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications . The pharmacy dispenses medications . in readily accountable quantities . The following information is completed: . quantity received . A review of the facility's P&P titled Medication Labels (April 2014), indicated . Improperly or inaccurately labeled medications are rejected and returned to the dispensing pharmacy . 555748 Page 15 of 19 555748 12/19/2024 Berkley East Healthcare Center 2021 Arizona Ave Santa Monica, CA 90404

F 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to ensure the standardized recipes for lunch menu was followed on 12/16/24 when: Residents Affected - Some 1.25 residents on mechanical soft diet (for resident who experience chewing or swallowing limitations) received Cajun country rice with sliced turkey instead of the Cajun country rice with ground turkey per menu and spreadsheet (food production guide includes food portion and serving guide). One resident on Dysphagia diet (for people with difficulty swallowing- food is moist, mechanical altered easily mashed, or pureed requires little chewing) received baked fish instead of ground fish, received regular Cajun Country rice instead of pureed rice per food production guides (food portion and serving guide). This deficient practice had the potential to result in meal dissatisfaction, decreased nutritional intake, weight loss and increased risk of choking for the residents who were on mechanical soft and dysphagia diet. Findings: According to the facility lunch menu for mechanical soft diet on 12/16/24, the following items will be served: Flaked and moist with fish fillet with tarragon sauce 3 ounces (3oz.); Cajun Country [NAME] with ground ham/turkey; creamed spinach with soft carrots, chopped corn salad, fruit Bavarian cream and beverage. For Dysphagia diet: Ground fish fillet with pureed tarragon sauce, Pureed Cajun country rice, Mashable and chop to ½ inch creamed spinach; pureed corn salad, Bavarian cream and beverage. During an observation of the tray line service for lunch on 12/16/24 at 12:00PM, the mechanical soft diet for Cajun Country [NAME] had large slices of turkey. During the same observation for lunch service on 12/16/24 one resident who was on dysphagia diet received baked fish that was flaked instead of ground and regular rice instead of pureed rice per the menu. During an interview with Cook1 on 12/16/24 at 12:30PM, Cook1 stated he used turkey slices instead of ham in the Cajun country rice because some residents don't like ham. Cook1 stated he chopped the turkey into 1 inch slices and he served the same rice to residents on regular diet and mechanical soft diet. During a concurrent review of the spreadsheet (food portions and serving guide), Cook1 stated he made a mistake, and he should have used ground turkey in the Cajun rice and not chopped pieces. Cook1 also stated one resident who is on the dysphagia diet should receive puree rice and ground fish. Cook1 stated when the pieces are large chops and it's the wrong texture residents can choke from the food. During a taste test of the mechanical soft and dysphagia diet on 12/16/24 at 12:40PM the pieces of the turkey in the Cajun country rice for the mechanical soft diet were large chopped into 1 inch and not ground. The Dysphagia diet received regular rice and not puree, and the fish was flaked instead 555748 Page 16 of 19 555748 12/19/2024 Berkley East Healthcare Center 2021 Arizona Ave Santa Monica, CA 90404

F 0803 of ground. Level of Harm - Minimal harm or potential for actual harm During an interview with Dietary Supervisor (DS) on 12/16/24 at 12:45PM, DS stated residents on mechanical soft diet should receive rice with ground turkey or ham and residents on dysphagia diet should receive puree rice and ground fish. DS stated cooks should always follow the menu and to be careful with texture modified diets are important to prevent choking. Residents Affected - Some During an interview with Registered Dietitian (RD1) on 12/17/24 at 10:00AM, RD1 stated the ham or turkey in the rice should be ground for the mechanical soft diet per the menu and the fish has to be ground and rice is pureed per the menu for dysphagia diet. RD1 stated mistakes had potential for residents choking. A review of facility policy and procedures titled Regular Mechanical soft diet (dated 2023) indicated, Meats poultry and fish allowed need to be ground with meat juices, gravy or sauce. A review of facility recipe for Fish with Tarragon Sauce indicated for dysphagia diet grind the fish and serve with pureed sauce. A review of facility recipe for the Cajun Country [NAME] indicated for mechanical soft Ham needs to be ground and the vegetables soft, for dysphagia diet puree the rice. 555748 Page 17 of 19 555748 12/19/2024 Berkley East Healthcare Center 2021 Arizona Ave Santa Monica, CA 90404

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure safe food handling practices when: Residents Affected - Some 1.One of one ice scooper was not cleaned and sanitized daily in accordance with the facility policy and procedure (P&P) titled, Ice Procedures. The ice scooper was not stored in a sanitary condition, the ice scooper had red color stains on it and was sticky. This deficient practice had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illness in101 out of 102 residents who received ice from the facility. Findings: During a concurrent observation and interview with Dietary Supervisor (DS) on 12/16/24 at 9:00AM the ice scooper was stored in the ice scoop container next to the ice machine. The Ice scooper had red stains on it and the stains were sticky to touch. DS stated it must be juice that is stuck on the ice scooper. DS stated the ice scooper is used to transfer ice from the ice machine and into water/juice pitchers for residents. DS stated the ice scoop is cleaned daily in the dishwasher and in the mornings. DS stated this must have happened after the daily cleaning. DS removed the ice scooper to the Dishwasher to wash. DS stated facility does not keep a log or a record of when the ice scooper is cleaned. DS stated when the scooper is dirty it can cross contaminate the ice. During a concurrent observation and interview with Dishwasher (DW) on 12/16/24 at 9:15AM, DW stated he works in the morning shifts. DW stated he washed the ice scooper today in the morning, he doesn't remember the time. DW stated he doesn't keep a record on days and time that he washes the scooper. During a review of the facility's policy and procedures (P&P) titled, Ice Procedures, (dated 2018) indicated, Ice scoops are to be washed in the dish machine daily by the PM Dishwasher or specify on the daily cleaning schedule who is to clean and when. A review of the 2022 U.S. Food and Drug Administration Food Code titled Equipment Food-Contact Surfaces and Utensils Code# 4-602.11, indicated, Surfaces of utensils and equipment contacting food that is not time/temperature control for safety food such as iced tea dispensers, carbonated beverage dispenser nozzles, beverage dispensing circuits or lines, water vending equipment, coffee bean grinders, ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. 555748 Page 18 of 19 555748 12/19/2024 Berkley East Healthcare Center 2021 Arizona Ave Santa Monica, CA 90404

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the reach in freezer was maintained in a good operating condition. The freezer had ice buildup inside the ceiling and walls. There was ice buildup on the door and the parameters of the door. Ice buildup on the door gasket and ice outside of the freezer door sealing the door and causing difficulty to open the freezer door. The freezer was operational in a manner that had the potential to affect food quality. Residents Affected - Few This deficient practice results in the inappropriate storage of food and had the potential to affect 101 out of 102 residents, who eat food from the facility kitchen. Findings: During an observation in the kitchen on 12/16/24 at 9:30AM the reach in Freezer Number 7 (F7) temperature was at -10degrees Fahrenheit. There was large amount of ice buildup outside of the freezer door on the edges. The ice was stuck around the door parameters, and it was difficult to open the freezer door. Inside the freezer there was ice buildup on the ceiling, the door and on the gasket (a flexible elastic stirp attached to the outer edge of a freezer door. Gasket is designed to form an air-tight seal that serves as a barrier between the cool air inside the appliance and the warmer external environment.) There were boxes of frozen food inside of the freezer, one package of the plant-based turkey alternative vegetarian food had frost buildup and discoloration. During a concurrent interview with Dietary Supervisor (DS) on 12/16/24 at 9:30AM, DS stated F7 has been accumulating ice and she knows about it. DS stated she has requested maintenance to fix it on 11/6/24. DS stated its hard to open the door of the freezer because the door gets stuck with the ice buildup around it. DS stated she will discard all the food inside the freezer because the quality may have been affected by the frost. During an interview with Maintenance supervisor (MS) on 12/16/24 at 10:00AM, MS stated that outside vendor had serviced the freezer, and he didn't know it was making ice again. MS stated he will look at the freezer. During an interview with MS on 12/17/24 at 12:21PM, MS stated his records indicated that the last time the vendor serviced the freezer was more than a year ago on 1/3/2023. MS stated they have removed and discarded the food from the freezer because ice can affect the quality and they are continuing to work to fix it. A review of facility policy titled Safety and Infection Control (dated 2018) indicated, The kitchen will be equipped with safe equipment, which is to be maintained in good working order. A review of facility policy and procedures titled Sanitation (dated 2018) indicated, The maintenance department will assist t Food and nutrition services as necessary in maintaining equipment . A review of facility policy and procedures titled Refrigerator and Freezer (dated 2018) indicated, Maintaining a clean refrigerator and freezer can improve the safety and quality of your foods. Periodically check door gaskets and replace if damaged, clean the evaporator and condensing coils at least twice a year, at least once a year ensure that drain lines are clean and all electrical connections are intact. 555748 Page 19 of 19