Health inspection·April 29, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive care plan that met the care/services based on the resident's individual assessed needs for one of five sampled residents (Resident 1) by failing to develop an individualized Care Plan (CP) for Resident 1 ' s behavior of removing his own wound dressing. This deficient practice had the potential to have a negative impact on residents ' health and safety, as well as the quality of care and services received. Cross Reference F686. Findings: During a review of the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including surgical aftercare following surgery on the circulatory system (body's network of blood vessels and heart that delivers oxygen and nutrients to cells and removes waste products), Type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), peripheral vascular disease (PVD - a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and chronic (a condition that persists for a long time, generally lasting three months or more) non-pressure ulcer (open sores on the skin that are not caused by pressure on the skin) of right ankle. The admission Record also indicated Resident 1 was discharged /transferred to General Acute Care Hospital 1 (GACH 1) on 4/4/2025. During a review of the Minimum Data Set (MDS – resident assessment tool) dated 3/28/2025 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 to maximal 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). During a review of Resident 1 ' s Care Plan as of 4/29/2025, there was no CP developed regarding Resident 1 ' s behavior of removing his own wound dressings. During a concurrent interview and record review with TXN 2 on 4/29/2025 at 1:17 p.m., TXN 2 stated Resident 1 had a behavior removing his own wound dressings and leaving it open to air. TXN 2 stated he would come during the day shift and the wound dressing from the previous day would already been removed. TXN 2 further stated, Resident 1 verbalized, he removed the old wound dressing because it was itchy. TXN 2 stated that the licensed nurses assigned to Resident 1 should have changed the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 555748 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555748 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkley East Healthcare Center 2021 Arizona Ave Santa Monica, CA 90404 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)