Health inspection·October 2, 2024

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 1 ' s care plan (a document that outlines the care and support a person needs, including the actions, interventions, and goals of their care), revised date on 9/5/24, the care plan indicated, The resident has .a communication problem r/t [related to] Respiratory impairment . Monitor/document for physical/nonverbal indicators of discomfort or distress, and follow-up as needed. During an interview on 10/2/24 at 12:18 p.m. with Registered Nurse (RN) 1, RN 1 stated facility procedure for residents with vital signs (objective measurement of the body ' s basic function such as blood pressure, heart rate, oxygen level, body temperature, and respiration rate) out of normal range would be addressed right away, and facility practice is to reassess the resident ' s vital sign, then administer any as needed physician standing (PRN - instructions already in place) orders for the abnormal vital sign. RN 1 further stated the attending physician would be notified of the abnormal vital sign if there were no standing orders, then the nurse will carry out the physician ' s orders. During an interview on 10/2/24 at 12:35 with Registered Nurse (RN) 2, RN 2 stated facility practice for residents with abnormal vital signs (vital signs outside of acceptable range) was to first assess the resident, then provide any PRN orders for the abnormal vital sign. RN 2 then stated the resident ' s attending physician would be notified if no PRN orders were available, the nurse would then carry out the new orders and reassess the resident after the intervention was given. During a concurrent interview and record review on 10/2/24 at 2:23 p.m. with the Risk Management Specialist (RMS), Resident 1 ' s vital signs EHR dated 9/20/2024 was review. The EHR indicated Resident 1 ' s heart rate was 106 bpm at 8:19 p.m. and the following heart rate documented was at 11:38 p.m. The RMS verified no vital sign was documented after 8:19 p.m. and before 11:38 p.m. During an interview on 10/2/24 at 4:12 p.m. with the Director of Quality and Risk Management (DQRM), the DQRM stated an assessment of the heart rate should be rechecked and documented after the nurse received notification of an abnormal heart rate and prior to administration of PRN orders. During a review of the facility ' s policy and procedure (P&P) titled Documentation, dated September 2022, the P&P indicated, Continuous reassessment of the patient is a nursing expectation, with documentation expected as changes occur. 2. During a review of Resident 3 ' s face sheet, (undated), the face sheet indicated Resident 3 was admitted on [DATE] with an admitting diagnosis of chronic respiratory failure (a long-term condition that makes it difficult to breathe). During a review of Resident 3 ' s Consultation Report (CR), dated 8/3/24, the CR indicated, . patient is in persistent vegetative state (a chronic condition where the patient is unable to respond to visual, auditory, tactile, or painful stimuli), chronic respiratory failure, manifests flaccid quadriplegia (a type of paralysis that causes the muscle in the limbs to become limp). During a review of Resident 3 ' s care plan (a document that outlines the care and support a person needs, including the actions, interventions, and goals of their care), undated, the Care Plan indicated, The resident is .Ventilator dependent r/t [related to] Respiratory Failure . Maintain muscle strength with active/active assistive/passive ROM and prevent contractures with use of splints [a medical device that stabilizes and immobilizes a body part]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555874 If continuation sheet Page 2 of 3 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 555874 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern California Hosp at Culver City D/P Snf 3828 Delmas Terrace Culver City, CA 90232 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 10/2/24 at 12:35 p.m., with RN 2, RN 2 stated ROM services was provided by the resident ' s assigned licensed nursing staff and documentation of services rendered was completed in the resident ' s EMR. During a concurrent interview and record review on 10/2/24 at p.m., with the Assistant Chief Nursing Officer (ACNO), Resident 3 ' s EHR of nursing tasks was review. The EHR indicated a nursing task of passive (movement of the body or limbs without the resident ' s effort) ROM to be provided every week on Sunday, Tuesday, and Friday at 1 p.m. The EMR was found blank on the dates of Friday 9/29/24 and Tuesday 10/1/24 for the passive ROM nursing task. The ACNO stated there was no documentation on Resident 3 ' s EHR on 9/29/24 and 10/1/24 that indicated Resident 3 received the ROM service. During a review of the facility ' s P&P titled Documentation, revised date September 2022, the P&P indicated, Physiologic monitoring data, treatments, procedures and other repetitive activities in the care of the patient are documented in the patient ' s medical record following the occurrence . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555874 If continuation sheet Page 3 of 3