Health inspection·April 11, 2024

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete A review of the facility's policy and procedure (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Care Plans, Comprehensive Person-Centered dated 12/2016, indicated a comprehensive, person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs . The P&P indicated, measurable objectives and timeframes include, incorporate identified problems areas, and incorporate risk factors associated with identified problems. The P&P indicated, areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. The P&P indicated, person-centered care plan is developed within seven days of the completion of the required comprehensive assessment. Event ID: Facility ID: 555786 If continuation sheet Page 2 of 5 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 555786 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ocean Park Healthcare 2828 Pico Boulevard Santa Monica, CA 90405 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)

F 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 32) received proper treatment and assistive devices to maintain vision abilities. Resident 32 has been missing corrective (prescription) eyeglasses since 03/18/2024. Residents Affected - Few This deficient practice resulted in Resident 32's decline in physical and psychosocial needs, as the resident was not able to enjoy hobbies including reading, watching television (TV), and socializing with the other residents. Findings: A review of Resident 32's admission Record, indicated the resident was re-admitted on [DATE] to the facility with diagnoses including traumatic subarachnoid hemorrhage without loss of consciousness (bleeding in the brain due to head injury), abnormalities of gait (a person's manner of walking) and mobility (ability to move freely and easily), muscle weakness (when muscles are weak causing difficulty performing normal activities that require strength), history of falling, major depressive disorder (a common but serious mood disorder that causes a persistent feeling of sadness and loss of interest), and generalized anxiety disorder (a condition of excessive worry about daily issues and situations). A review of Resident 32's Minimum Data Set (MDS - a standardized assessment and care planning tools), dated 01/7/2024, indicated Resident 32 wore corrective lenses. MDS indicated Resident 32 had a moderately impaired cognition (make poor decisions, cues and supervisions required). A review of Resident 32's history and physical (H&P - a physician's complete patient examination), dated 03/20/2024, indicated, Resident 32 could make needs known but could not make medical decisions. A review of Resident 1's Social Services (SS) progress notes, dated 03/20/2024 at 12:38 PM, indicated, Resident 32 informed Social Services Director (SSD - manages and coordinates social service programs [ex. housing, mental health, healthcare] and organizations that provides assistance to people in need) that Resident 32's corrective eyeglasses were missing from Resident 32's room. SS notes indicated SSD acknowledged that Resident 32's eyeglasses were missing, and that SSD provided Resident 32 with a pair of reading eyeglasses. A review of SS progress notes, dated 03/26/2024 at 10:53 AM, indicated, Resident 32's medical power of attorney (MPOA), called to request contact number of Resident 32's optometrist (is a healthcare professional who provides primary vision care ranging from sight testing and correction to the diagnosis, treatment, and management of vision changes). During an interview with Resident 32 on 04/08/24 at 12 PM, Resident 32 stated, SSD gave Resident 32 a pair of reading eyeglasses which did not work for Resident 32, because Resident 32 wears tri-focal eyeglasses (are eyeglasses with lenses that have three regions which correct distance, intermediate, and near vision). Resident 32 stated Resident 32 enjoys watching TV and reading the newspaper but has given them all up because Resident 32 was struggling to watch TV and read newspapers. Resident 32 stated Resident 32 felt unsafe because Resident 32 might fall and get hurt due to impaired vision. Resident 32 stated Resident 32 could not join any of the activities offered in the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555786 If continuation sheet Page 3 of 5 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 555786 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ocean Park Healthcare 2828 Pico Boulevard Santa Monica, CA 90405 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)

F 0685 because Resident 32 could not see well without corrective eyeglasses. Level of Harm - Minimal harm or potential for actual harm During an interview with Licensed Vocational Nurse 3 (LVN 3) dated 04/08/2024 at 3:31 PM, LVN 3 stated, Resident 32 liked watching TV and reading newspaper. LVN 3 stated LVN 3 asked Resident 32 what happened to the eyeglasses, and Resident 32 replied it went missing from Resident 32's room in the facility while Resident 32 was hospitalized . LVN 3 stated LVN 3 noticed that lately, Resident 32 was no longer watching TV or reading newspapers. Residents Affected - Few During an interview with Certified Nursing Assistant 3 (CNA 3) on 04/09/2024 at 8:56 AM, CNA 3 stated, Resident 32 wore eyeglasses all the time. CNA 3 stated, lately CNA 3 has not seen Resident 32 watch TV or read a newspapers. A review of SS progress notes dated 04/10/2024 at 3:49 PM, indicated, Interdisciplinary Team (IDT - a group of different healthcare professionals working together towards a common goal for a resident) discussed with MPOA that Resident 32 was seen by an optometrist for replacement of eyeglasses on 03/27/2024. SS progress notes indicated, IDT discussed with MPOA Resident 32's that insurance for Resident 32, did not cover replacement for Resident 32's corrective glasses. SS progress notes indicated Resident 32's eyeglasses prescription would be emailed to MPOA as soon as SSD received the prescription via email. During an interview with LVN 4 on 04/11/2024 at 10:25 AM, LVN 4 stated LVN 4 had seen Resident 32 wearing eyeglasses all the time. LVN 4 stated Resident 32 enjoyed watching TV and reading newspapers. LVN 4 stated the last time (date/time not specified) LVN 4 saw Resident 32, Resident 32 was in Resident 32's room instead of socializing with other residents in the dining room. A review of Resident 32's SS progress notes dated 04/11/2024 at 10:32 AM, indicated, MPOA received the eyeglass prescription from SSD. SS progress notes indicated, MPOA picked up Resident 32 and took Resident 32 to an optometry office to pick out Resident 32's replacement frame for the eyeglasses. During an interview with Director of Nursing (DON) on 04/11/2024 at 11:56 AM, DON stated Resident 32 wore eyeglasses every day. When asked how Resident 32 was performing without eyeglasses, DON stated, it was difficulty for [Resident 32]. DON stated Resident 32 did not go to the dining room to socialize with the other residents because Resident 32 could not enjoy watching TV and reading a book without eyeglasses. DON stated Resident 32 could be a fall risk since Resident 32 was not able to see well. A review of the facility's policy and procedures (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Investigating Incident of Theft and/or Misappropriation of Resident Property, dated 04/2021, indicated, residents have the right to be free from .theft .of personal property. The P&P indicated; the facility provides measures to safeguard resident valuables . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555786 If continuation sheet Page 4 of 5 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 555786 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ocean Park Healthcare 2828 Pico Boulevard Santa Monica, CA 90405 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)

F 0942 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. Based on interview and record review, the facility failed to ensure one of two training records years (2022) on mandated reporter on abuse, was completed. Facility failed to validate that training documentation on mandated reporter on abuse by facility's staff was completed in 2022. This deficient practice had the potential for staff members not to understand/be educated/be informed on the rights of the resident and the responsibilities of a facility to properly care for its residents regarding mandated reporter. Findings: During an interview with Licensed Vocational Nurse 3 (LVN 3) on 04/08/2024 at 3:31 PM, LVN 3 stated LVN 3 received training on mandated reporter on abuse yearly. LVN 3 named the facility's abuse coordinator as the administrator (Adm). LVN 3 stated if LVN 3 witnesses an alleged abuse, LVN 3 will report the abuse allegation to the administrator no more than two hours from the time the alleged abuse happens. During an interview with Certified Nursing Assistant 3 (CNA 3) on 04/9/2024 at 8:56 PM, CNA 3 stated CNA 3 received training on mandated reporter on abuse annually. CNA 3 stated if CNA 3 witnesses an abuse, CNA 3 will report the abuse to the abuse coordinator, Adm, within two hours of the alleged abuse incident. During an interview with Adm on 04/11/2024 at 3:04 PM, Adm stated the facility could not find the training documents on mandated reporter on abuse for 2022. During an interview of Social Services Director (SSD - manages and coordinates social service programs [ex. housing, mental health, healthcare] and organizations that provides assistance to people in need) on 4/10/2024 at 3:39 PM, SSD stated SSD received training on mandated reporter on abuse yearly. SSD stated SSD will report all types of abuse to the facility's abuse coordinator, Adm, or the DON, or any of the supervisors. SSD stated the any allegation of abuse, should be reported within two hours. A review of the facility's policy and procedures (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks), dated 02/2021, indicated, in-service and training records (hard copy and digital copy) are maintained for four years . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555786 If continuation sheet Page 5 of 5