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. (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 4 Event ID: 555786 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 01/16/2025 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)