Health inspection·May 1, 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 sufficient preparation and orientation for one of four sampled residents, (Resident) 1 with a safe and orderly discharge planning by failing to: 1. Follow-up on the Interdisciplinary Team (IDT - a group of dedicated healthcare professionals who work to bring knowledge together to help residents receive the care they need) Care Conference meeting regarding Resident 1 ' s discharge planning during admission. 2. Ensure Resident 1 ' s are provided with necessary care and services upon discharge to home. These deficient practices resulted in incomplete and ineffective discharge planning that may lead to lack of necessary care, accident and possible injury after discharge. Findings: During a review of Resident 1 ' s admission Record, it indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including infrarenal abdominal aortic aneurysm (AAA - is a bulge or weakening in the main blood vessel that runs through the belly, specifically below the arteries that supply blood to the kidneys), type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness (weakening, shrinking, and loss of muscle), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). The admission Record also indicated, Resident 1 was discharged home on 4/28/2025. During a review of the Minimum Data Set (MDS – resident assessment tool) dated 4/12/2025, indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately 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). During a review of Resident ' s History and Physical, dated 4/9/2025, it indicated that, Resident 1 has fluctuating capacity to understand and make decisions – risk for delirium ((a serious disturbance in a person's mental abilities that results in a decreased awareness of one's environment and confused thinking). The H&P also indicated, Patient (Resident 1) lives at home alone . Resident 1 ' s majority of family in Central California and concerned about him (Resident 1) living alone . He (Resident 1) has been declining, but on the surface still appears to manage adequately and is able to compensate and mask deficits. However, they know he is not safe and has had more memory loss and Page 1 of 2 555748 555748 05/01/2025 Berkley East Healthcare Center 2021 Arizona Ave Santa Monica, CA 90404

F 0627 cognitively also has had more deficits. Level of Harm - Minimal harm or potential for actual harm During an interview with General Acute Care Hospital Social Worker 1 (GACH SW1) on 5/1/2025 at 8:44 a.m., GACH SW 1 stated, Resident 1 was discharged home alone from the facility on 4/28/2025 without a CG. GACH SW 1 stated, they have recommended Resident 1 to be discharged to an Assisted Living Facility (ALF - a type of housing that provides both housing and personal care services to people who need assistance with daily living activities, but who don't require the medical care of a nursing home) as he (Resident 1) was not safe to be home alone because of his comorbidities and home situation. Residents Affected - Few During a review of Resident 1 ' s Care Plan (CP) for discharge, initiated on 4/10/2025, the CP indicated a goal of, Resident (1) will be able to verbalize/communicate required assistance post-discharge and the services required to meet needs before discharge. During a review of Resident 1 ' s Discharge Planning Review, dated 4/10/2025, it indicated that, Resident (1) lives alone . concerns are including: will need a Caregiver (CG). During a review of Resident 1 ' s IDT Care Conference Meeting, dated 4/22/2025, the IDT Care Conference indicated that, Plan: Recommended home health follow-up and CG for safety . Resident (1) was provided with different brochures for Caregiver Agencies since CG are recommended upon discharge . Resident (1) lives alone on an apartment . During a review of Resident 1 ' s Discharge summary, dated [DATE], it indicated that, Resident (1) was discharged to home with Home Health, ADL: independent. The DC summary does not indicate if Resident 1 was provided with a CG. During an interview with SSA 1 on 5/1/2025 at 3:22 p.m., SSA 1 stated, Resident 1 was discharged home on 4/28/2025 with Home Health. SSA1 stated that there was no information about if Resident 1 was discharged with a CG at home. During an interview with SSA 2 on 5/1/2025 at 3:55 p.m., SSA 2 stated, Resident 1 was given brochures regarding CG agencies as he was recommended to go home with a Home Health Provider and a CG. SS2 stated Resident 1 was provided with CG agencies, but Resident 1 stated, he cannot afford a CG. SSA2 stated that no information was provided to Resident 1 regarding ALF as an option for discharge planning. During a concurrent interview with the Social Services Director (SSD) on 5/1/2025 at 4:16 p.m., SSD stated, if a resident was given a recommendation to be discharged with a CG and/or be transferred to an ALF during discharge planning, they need to follow-up on the recommendation by providing resources and information and documenting it on the medical record. SSD stated, if not, this may negligibly affect the residents as Resident 1 may not be safe to be home alone. During a review of the facility ' s policy and procedure (P&P), titled, Transfer or Discharge, Resident-Initiated, revised on 1/2025, the P&P indicated that, For resident-initiated discharges, the medical record contains: Documentation: a. documentation or evidence of the resident's or resident representative's verbal or written notice of intent to leave the facility; b. a discharge care plan; and c. documented discussions with the resident or, if appropriate, his/her representative, containing details of discharge planning and arrangements for post-discharge care. 555748 Page 2 of 2