Health inspection·January 16, 2025

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that Certified Nursing Assistants (CNA 6 and CNA 5) carried out activities of daily living (ADL- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) services and implemented interventions in accordance with the resident's assessed needs for one of three sampled residents (Resident 1) per facility's policy and procedure (P&P). Residents Affected - Few This deficient practice resulted in Resident 1's toileting, bathing needs not being met, which could negatively affect the resident's health and wellbeing. Findings: A review of the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood), urinary tract infection (UTI- an infection in the bladder/urinary tract), unspecified dementia (a progressive state of decline in mental abilities) and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities). A review of the Minimum Data Set (MDS - resident assessment tool) dated 12/2/2024, indicated Resident 1's cognitive (relating to mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 2 required maximal assistance from staff for ADLs. A review of Resident 1's History and Physical (H&P) dated 8/30/2024 indicated, Resident 1 did not have the capacity to understand and make medical decision. A review of Resident 1's Care Plan, indicated Resident 1 has an ADL self-care and/or mobility performance deficit, with interventions including to assist resident in turning and/or repositioning every 2 hours and as needed (PRN). During an interview with CNA 6 on 1/15/2024 at 12:40 p.m., CNA 6 stated, she worked as a sitter during one of the night shifts and from her understanding, sitter does not do any ADL care such as repositioning, feeding and monitoring resident's incontinence brief. CNA 6 stated, CNA 5 who was assigned to Resident 1 that night also did not do any ADL care on Resident 1 until the end of the shift and CNA 5 did not check on Resident 1 throughout her whole shift. When asked if she completed the sitter behavior log that shift, CNA 6 did not answer. Page 1 of 4 555786 555786 01/16/2025 Ocean Park Healthcare 2828 Pico Boulevard Santa Monica, CA 90405

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 1/15/2025 at 12:23 p.m., CNA 5 stated, she was assigned to Resident 1 on the night when CNA 6 was assigned as the sitter. CNA 5 stated, when a CNA is assigned as a sitter, they can also assist residents during ADL care and monitor resident. CNA 5 stated, she checked on Resident 1 only during the end of her shift. During an interview with Director of Staff and Development (DSD) on 1/15/2025 at 2:09 p.m., DSD stated, when a resident has a sitter assigned to them and the sitter are certified nursing assistants, they are to also do ADL care on that resident such as checking incontinent briefs and repositioning. DSD stated CNAs are expected to help and assist since they are only assigned to one resident. During an interview with Director of Nursing (DON) on 1/15/2025 at 2:36 p.m., DON stated, residents are to be repositioned and staff are to ensure that residents are kept clean and dry. A review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL), Supporting dated 3/15/2024, indicated, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. A review of the facility's P&P titled, Urinary Incontinence - Clinical Protocol, dated 3/15/2024, indicated, As appropriate, based on assessment of the category and causes of incontinence, the staff will provide scheduled toileting, prompted voiding, or other interventions to try to improve the individual's continence status. A review of the facility's Job Description titled, Certified Nursing Assistant (CNA), Updated 10/2010, indicated, Position Summary: Provides routine daily nursing care and services in accordance with the care plan of each resident based on established nursing care procedures and at the direction of supervisor. Ensures resident's needs are maintained with highest degree of dignity . Duties and Responsibilities includes: Performs comprehensive resident care duties Including but not limited to bathing, taking vital signs, changing linens, properly positioning residents and giving AM and PM care. 555786 Page 2 of 4 555786 01/16/2025 Ocean Park Healthcare 2828 Pico Boulevard Santa Monica, CA 90405

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one of three sampled residents (Resident 1) by failing to: Residents Affected - Few 1. Ensure Resident 1 who required maximal assistance with repositioning had been turned and repositioned according to the resident's care plan (CP). 2. Ensure Resident 1 who was incontinent of bladder had been kept clean to prevent urinary tract infections (UTI- an infection in the bladder/urinary tract) to the extent possible and prevent skin injury. These deficient practices resulted to failure in the delivery of necessary care and services including repositioning and incontinence care for Resident 1. Findings: A review of the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood), urinary tract infection, unspecified dementia (a progressive state of decline in mental abilities) and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities). A review of the Minimum Data Set (MDS - resident assessment tool) dated 12/2/2024, indicated Resident 1's cognitive (relating to mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 2 required 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). A review of Resident 1's History and Physical (H&P) dated 8/30/2024 indicated, Resident 1 did not have the capacity to understand and make medical decision. A review of Resident 1's Care Plan, indicated Resident 1 had an ADL self-care and/or mobility performance deficit, with interventions including to assist resident in turning and/or repositioning every 2 hours and as needed (PRN). During an interview with Certified Nursing Assistant (CNA 6) on 1/15/2024 at 12:40 p.m., CNA 6 stated, she worked as a sitter during one of the night shifts and from her understanding, sitter does not do any ADL care such as repositioning, feeding and monitoring resident's incontinence brief. CNA 6 stated, CNA 5 who was assigned to Resident 1 that night also did not do any ADL care on Resident 1 until the end of the shift and CNA 5 did not check on Resident 1 throughout her whole shift. When asked if she completed the sitter behavior log that shift, CNA 6 did not answer. During an interview on 1/15/2025 at 12:23 p.m., CNA 5 stated, she was assigned to Resident 1 on the night when CNA 6 was assigned as the sitter. CNA 5 stated, when a CNA is assigned as a sitter, they can also assist residents during ADL care and monitor resident. CNA 5 stated, she checked on Resident 1 only during the end of her shift. 555786 Page 3 of 4 555786 01/16/2025 Ocean Park Healthcare 2828 Pico Boulevard Santa Monica, CA 90405

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with Director of Staff Development (DSD) on 1/15/2025 at 2:09 p.m., DSD stated, when a resident has a sitter assigned to them and the sitter is a certified nursing assistant, the sitter should also do ADL care on that resident such as checking incontinent briefs and repositioning. DSD stated CNAs working as sitters are expected to help and assist since they are only assigned to one resident. During an interview with Director of Nursing (DON) on 1/15/2025 at 2:36 p.m., DON stated, residents are to be repositioned and staff are to ensure that residents are kept clean and dry. During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL), Supporting dated 3/15/2024, the P&P indicated, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. During a review of the facility's P&P titled, Urinary Incontinence - Clinical Protocol, dated 3/15/2024, the P&P indicated, As appropriate, based on assessment of the category and causes of incontinence, the staff will provide scheduled toileting, prompted voiding, or other interventions to try to improve the individual's continence status. 555786 Page 4 of 4