Other·March 2, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an annual recertification survey. Representing the Department of Health: Health Facilities Evaluator Nurse ID: 36923 Health Facilities Evaluator Nurse ID: 36627 Highest Severity and Scope = L Total Resident Census: 44 Sample Size: 25 On January 10, 2018 at 5:30 p.m., an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) was called under F812 cross refer F925, in the presence of the facility Administrator and Director of Nursing. A unacceptable plan of action was submitted to the survey team on January 10, at 7:30 p.m. An acceptable plan of action was submitted to the survey team on on January 11, 2018, at 4:02 p.m., validated through observation, interview, and record review to verify facility compliance. The acceptable plan of action included: 1. The facility immediately obtained a new pest control company and provided emergency service to the affected areas. 2. The facility deep cleaned all affected areas in the kitchen and the emergency food storage LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 1 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE area. 3. The facility repaired damaged walls in the kitchen. 4. The facility replaced cracked and damaged tiles. 5. The facility vacuumed to remove food and debris from cracks and crevices. 6. Inservice and routine training for staff including checking for pests daily and reporting any sighting of pests was conducted by the Administrator and the Director of Staff Development for pest control management. 7. All surfaces/underneath counters, exposed cooking utensils, shelving, exposed unsealed containers, were deep cleaned and sanitized with approved kitchen sanitizer. 8. All exposed food was thrown away. 9. The facility implemented immediately recommendations provided by the new pest control company to ensure no pest control issues affect food, prep areas, patient care areas or any other areas of the facility. 10. The laundry room and the emergency food area was treated with pest abatement. The Immediate Jeopardy was abated on January 11, 2018 at 4:03 p.m. in the presence of the Administrator, when the facility implemented adequate measures to irradiate and prevent infestation of roaches, provide a sanitary kitchen and food storage area and was able to demonstrate knowledge of services necessary to ensure effective pest control management.

F550 SS=D Resident Rights/Exercise of Rights CFR(s): 483.10(a)(1)(2)(b)(1)(2)

F550 03/14/2018 §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 2 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to enhance a resident's dignity and respect by failing to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 3 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ensure predetermined showers were provided as scheduled for one out of 25 sampled residents (Resident 24). This deficient practice had the potential to negatively affect the resident's psychosocial wellbeing. Findings: A review of the admission record indicated Resident 24 was admitted to the facility on December 6, 2017 with diagnoses that included muscle weakness and difficulty in walking. A review of Resident 24's History and Physical report completed on December 10, 2017 indicated the resident had the capacity to understand and make decisions. A review of Resident 24's Minimum Data Set [MDS- a comprehensive assessment and screening tool] dated December 13, 2017, indicated the resident was cognitively intact. Resident 24 required extensive one-person assist with toilet use, personal hygiene, and bathing. A review of the care plan dated December 7, 2017 indicated Resident 24 required assistance with ADL due to decreased strength and balance. The care plan goal indicated the resident will have increased ADL independence daily until next review. The care plan intervention indicated to assist with showers and toileting as needed. A review of the resident's shower schedule indicated Wednesdays and Saturdays as shower days for Resident 24. On January 10, 2018 at 2:49 p.m., during an interview, Resident 24 stated that some facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 4 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE staff members were not treating her in a dignifying manner ("made certain remarks" to her). Resident 24 stated that she has had a bad experience since her admission (December 6, 2017) in the facility. On January 10, 2018 at 3:08 p.m., during an observation, Resident 24 was sitting in her chair, awake, alert, and responding appropriately to questions. During a concurrent interview, Resident 24 stated that she had not received a shower since her admission to the facility on December 6, 2017. Resident 24 stated that the nursing staff told her that she could not receive a shower because of the wound dressing on left foot. When asked how it made her feel not to receive a shower for a month, Resident 24 stated "if you look at me that's not me, I am not able to keep up with my hair, I am sick and tired of sponge bath". Resident 24 also stated that she lost her dignity. On January 11, 2018 at 11:11 a.m., during an interview, the Director of Nursing (DON) stated that residents have pre-determined shower schedule. The DON stated that Resident 24's wound dressings on her lower extremities should not have prevented the nursing staff from providing Resident 24 with a shower.

F552 SS=D Right to be Informed/Make Treatment Decisions CFR(s): 483.10(c)(1)(4)(5)

F552 03/14/2018 §483.10(c) Planning and Implementing Care. The resident has the right to be informed of, and participate in, his or her treatment, including: §483.10(c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 5 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE limited to, his or her medical condition. §483.10(c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care. §483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility licensed staff failed to obtain informed consent from the resident or resident's responsible party before increasing the dosage of an antipsychotic medication, a drug used to treat serious mental health conditions, (Zyprexa) ordered for major depressive disorder with psychosis, a severe mental disorder (as manifested by hallucination- perception of something not present, with severe agitation and ensure that the risk and benefit was explained to the resident prior to obtaining the informed consent (Resident 30) for one out of 25 sample residents (Resident 30). This deficient practice violated the resident's right to be fully informed and consent to receive psychoactive medications. Findings: On January 16, 2018 at 1:15 p.m., Resident 30 was observed sitting up in the chair and eating his lunch. The resident was calm and pleasant. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 6 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated December 17, 2017, indicated Resident 30 was admitted to the facility on December 10, 2017, with diagnoses that included anxiety disorder. A review of the Physician's Order dated January 3, 2018, indicated an order for Zyprexa 1.25 milligram (mg) twice a day for major depressive disorder with psychosis manifested by hallucination with severe agitation. A review of another Physician's Order dated January 10, 2018, indicated to give the resident Zyprexa 1.25 mg daily at 9:00 a.m., and 2.5 mg every night at 9:00 p.m. for major depressive disorder with psychosis manifested by hallucination with severe agitation. A review of the Medication Administration Record indicated Resident 30 has been receiving the increase dose of the medication at night since January 10, 2018. A review of the Facility Verification of Informed Consent to Physical Restraints, Psychotherapeutic Drug or "Prolonged Use of Active Device" dated January 10, 2018, indicated the licensed nurse signed the form indicating the physician has verbally indicated that consent has been obtained and resident/responsible party has given consent to physician for the above treatment. On January 17, 2018 at 11:15 a.m., during an interview, Resident 30's Family Member 30 (FM 30)stated the facility did not inform her that the doctor had increased the dose of the medication. On January 17, 2018 at 11:50 a.m., during an interview, Licensed Vocational Nurse 5 (LVN 5) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 7 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE stated that she did not verify with the resident's representative if she has given consent to the physician to increase the dose of the medication since the doctor had already obtained the consent. On January 17, 2018 at 2:30 p.m., during an interview, the Director of Nursing (DON) stated that the family was not notified that the dose of the medication was increased. A review of the facility's undated policy and procedure titled, "Informed Consent for Psychotropics, Physical Restraints and Medical Devices Policy," indicated the facility is to involve residents in their care decision...consent for the use of psychotherapeutic drugs...which may lead to inability to regain use of a body function after prolonged use. When a new or significantly changed order for a psychotherapeutic, physical restraint or medical device is obtained, the licensed nurse verifies with the physician that informed consent has been obtained.

F584 SS=D Safe/Clean/Comfortable/Homelike Environment F584 CFR(s): 483.10(i)(1)-(7) 03/16/2018 §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 8 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; §483.10(i)(3) Clean bed and bath linens that are in good condition; §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2) (iv); §483.10(i)(5) Adequate and comfortable lighting levels in all areas; §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and §483.10(i)(7) For the maintenance of comfortable sound levels. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to maintain a comfortable noise level for one of 25 sampled resident (Resident 148). This deficient practice has the potential negatively affect the resident's quality of life. Findings: A review of the admission record indicated Resident 148 was admitted to the facility on December 26, 2017. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 9 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Minimum Data Set [MDS- a comprehensive assessment and screening tool] dated November 22, 2017, indicated Resident 148 had intact cognition. On January 10, 2018 at 10:42 a.m., during an observation, the resident was sitting at the edge of the bed, awake, alert, and oriented to person, place, time, and situation. During a concurrent interview, Resident 148 stated that the facility was noisy during the night (staff members socializing amongst themselves, roommate making noise). Resident 148 stated that she could not sleep the night prior (January 9, 2018). Resident 148 also stated that the utility room was located near her room and it would get noisy when the staff member would get trash bags. During the interview, a staff member was observed opening the utility room and pulling a trash bag from a metal container that was mounted on the door, a loud audible sound was heard. On January 12, 2018 at 3:48 p.m., during an interview, the Social Service Director (SSD) stated that the resident was complaining of noise when she was originally admitted to the facility. The SSD also stated that Resident 148 had a room change because of the noise level near her room (located next to the exit). A review of the facility's undated policy titled "Quality of Life- Homelike Environment" indicated that the staff shall provide personcentered care that emphasizes the residents' comfort, independence, and personal needs and preferences. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include comfortable noise levels. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 10 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F623 Notice Requirements Before Transfer/Discharge CFR(s): 483.15(c)(3)-(6)(8)

F623 SS=B PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 03/14/2018 §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State LongTerm Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 11 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 12 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure a resident's notice of transfer or discharge was provided to the residents and to notify the State long Term Care Ombudsman (public advocate) prior to transfer or discharge from the facility for two of 25 sample residents (Resident 18 and 48). This deficient practice had the potential to deny residents' protection from being inappropriately discharged. Findings: a. On January 10, 2018 at 11:00 a.m., during the initial tour of the facility, Resident 18's Family member (FM 18) stated Resident 18 was to be discharged on January 11, 2018. FM 18 stated he wanted the resident to stay for more physical therapy. A review of the admission record indicated Resident 18 was admitted to the facility on November 15, 2017, with diagnoses that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 13 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE included difficulty walking and left intertrochanteric fracture (left hip fracture). A review of Resident 18's Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated December 13, 2017, indicated Resident 18's cognitive (relating to the process of acquiring knowledge and understanding) and decision making skills were severely impaired. A review of the social services note dated January 10, 2018 at 7:29 p.m., indicated Resident 18 was scheduled for discharge on January 11, 2017. On January 11, 2018 at 9:21 a.m., during an interview, the Social Services Director(SSD) stated she was not aware of any other document given to the residents and responsible parties regarding notification of discharge and transfer. The SSD stated medical record staff were responsible for notifying the Ombudsman. On January 11, 2018 at 9:56 a.m., during an interview, the Medical Record Staff 1 (MR 1) stated that at the end of every month, he faxed a list of all the residents that were discharged to the Ombudsman's office. MR 1 stated he was not responsible for notifying the Ombudsman in advance regarding planned upcoming discharges. On January 11, 2018 at 10:04 a.m., during an interview, the Director of Nursing (DON) stated the Interdisciplinary (IDT-a coordinated group of experts from several different fields) notes regarding discharge are given to the residents or their representatives prior to discharge. The DON also stated the facility did not have any other form or written discharge notice to give to residents or their representatives. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 14 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On January 12, 2018 at 4:24 p.m., during an interview, the DON stated she was not aware the notice of transfer or discharge form was supposed to be done and provide a copy to the resident. The DON also stated she was not aware that a copy of the notice should be sent to the Ombudsman before or as close as possible to the actual time of transfer or discharge. A review the facility's undated policy and procedure titled "Notice of a Transfer or Discharge" indicated the facility shall provide a resident and or the resident's representative with a thirty day written notice of an impending transfer or discharge. According to the policy and procedure, the contents of the notice will be provided with the following information: the reason for the transfer or discharge, the effective date of the transfer or discharge, the location which the resident is being transferred or discharged, the name, address and telephone number of the state long term care ombudsman, and the name address and telephone number of the state health department agency that has been designated to handle appeals or transfer and discharges. b. A review of the admission record indicated Resident 48 was admitted to the facility on October 12, 2017, with diagnoses that included artificial right knee joint and osteoarthritis (damage of joint cartilage and the underlying bone that causes pain and stiffness, especially in the hip, knee, and thumb joints). A review of Resident 48's Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated October 16, 2017, indicated Resident 48's cognitive (relating to the process of acquiring knowledge and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 15 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE understanding) and decision making skills were intact. A review of Resident 48's Physician's Orders dated October 15, 2017, indicated to discharge home on October 16, 2017, with home health for physical therapy and occupational therapy for safety evaluation and treatment and a registered nurse for medication reconciliation and treatment. On January 11, 2018 at 9:21 a.m., during an interview, the Social Services Director(SSD) stated she was not aware of any other document that should be given to the residents and responsible parties regarding notification of discharge and transfer. The SSD stated medical record staff were responsible for notifying the Ombudsman. On January 11, 2018 at 9:56 a.m., during an interview, Medical Records Staff 1 (MR 1) stated that at the end of every month, he faxed a list of all the residents that were discharged to the Ombudsman's office. MR 1 stated he was not responsible for notifying the Ombudsman in advance regarding planned upcoming discharges. On January 11, 2018 at 10:04 a.m., during an interview, the Director of Nursing (DON) stated the Interdisciplinary (IDT) notes regarding discharge are given to the residents or their representatives prior to discharge. The DON also stated the facility did not have any other form or written discharge notice to give to residents or their representatives. On January 12, 2018 at 4:24 p.m., during an interview, the DON stated she was not aware that the notice of transfer or discharge form was supposed to be done and provide a copy to the resident. The DON also stated she was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 16 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE not aware that a copy of the notice should be send to the Ombudsman before or as close as possible to the actual time of transfer or discharge. A review the facility's undated policy and procedure titled "Notice of a Transfer or Discharge" indicated the facility shall provide a resident and or the resident's representative with a thirty day written notice of an impending transfer or discharge. According to the policy and procedure, the contents of the notice will be provided with the following information: the reason for the transfer or discharge, the effective date of the transfer or discharge, the location which the resident is being transferred or discharged, the name, address and telephone number of the state long term care ombudsman, and the name address and telephone number of the state health department agency that has been designated to handle appeals or transfer and discharges.

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 03/14/2018 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 17 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the nursing staff failed to implement, update, and/or revised the care plan for one of 25 sampled residents (Resident 24), who was experiencing severe pain to her lower extremities and was at risk for fall. This deficient practice had the potential to negatively affect the resident's physical and psychosocial wellbeing and place the resident at risk for injuries in case of a fall. Findings: a.1. A review of the admission record indicated Resident 24 was admitted to the facility on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 18 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE December 6, 2017, with diagnoses that included muscle weakness, difficulty in walking, multiples fractures of ribs, and chronic ulcers of the lower extremities. A review of Resident 24's History and Physical report completed on December 10, 2017, indicated the resident had the capacity to understand and make decisions. A review of Resident 24's Minimum Data Set [MDS- a comprehensive assessment and screening tool] dated December 13, 2017, indicated the resident was cognitively intact. Resident 24 required extensive one-person assist with toilet use, personal hygiene, and bathing. The MDS indicated was occasionally experiencing pain rating nine out of 10, on a zero to 10 numeric pain rating scale, zero being no pain and 10 being the worst possible pain. The MDS also indicated Resident 24 had a history of fall in the past month. A review of the care plan dated December 6, 2017, indicated Resident 24 had alteration in pain related to left rib fracture and cervical vertebrae fracture. The goal indicated the resident's pain will be decreased or controlled as evidenced by decreased request of pain medication. The care plan interventions indicated to assess and document characteristics of pain, provide comfort measured, administer medications as ordered, monitor for effectiveness, and notify the physician if ineffective. A review of Resident 24's physician order dated December 27, 2017, indicated to give the resident Norco (an opioid pain medication) 325 milligram (mg)- 5 mg, one tablet oral every four hours as needed for severe pain (8-10/10). On January 10, 2018 at 10:49 a.m., during an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 19 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE observation, Resident 24 was lying in bed and grimacing. During a concurrent interview, Resident 24 stated she was having foot pain. Resident 24 stated that she did not sleep well the night prior because of pain. Resident 24 stated that she requested pain medication on January 10, 2018 at 3 a.m., but was told it was too early to receive her pain medication. The nursing staff told her that she could not get the pain medication till 5 a.m. A review of the pain assessment flow sheet indicated Resident 24 received Norco 325 mg-5 mg for severe pain in her lower extremities 75 times From December 8, 2017 to January 10, 2018. On January 10, 2018 at 3:10 p.m., during a follow-up interview, Resident 24 stated that she knew it was 3 a.m. the morning of January 10, 2018, when she requested pain medication because she looked at the clock. Resident 24 stated that she could not sleep because of pain on her left leg, which at that time was 10 out of 10 on a zero to 10 pain rating scale. Resident 24 stated that the nursing staff told her that she could not give her pain medication till 5 a.m. (her next scheduled dose). Resident 24 stated that she "pleaded, begged" the nursing staff that she could not wait for 2 hours because she was in so much pain. Resident 24's family member (FM 1), who was present during the interview, stated that it was not the first time that the resident had requested pain medications and was asked to wait for her next scheduled dose. FM 1 stated Resident 24 called her earlier during the day and stated that she did not sleep because of pain, requested pain med, but the nurse told her it was not time for her pain medication. FM 1 also stated that Resident 24's left foot has been hurting for about 2 weeks. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 20 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On January 12, 2018 at 12:35 p.m., during an interview, the Director of Nursing (DON) stated that she reviewed Resident 24's initial pain evaluation and the evaluation did not address the resident's pain in her lower extremities. The DON also stated that Resident 24's care plan related to alteration in comfort did not address her lower extremities. The DON stated that Resident 24's care plan should have addressed the resident's lower extremities since the resident was receiving pain management for the lower extremities. The DON stated that there was no comprehensive assessment/evaluation regarding the resident's pain on her lower extremities. A review of the facility's undated policy titled "Pain Assessment and Management" indicated that it is the policy of the facility to assure that resident's pain is identified, monitored, and managed to provide relief in order to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Resident's pain status is assessed by a licensed nurse upon admission, every shift, complaint of new pain, before, during, and after care/treatment of therapy, and quarterly. The licensed nurse will administer pain medication per physician orders. The effectiveness of pain management interventions is evaluated and documented. A pain management plan of care is initiated, re-evaluated, or revised by the licensed nurse to include non-medication interventions that may be helpful either alone or in conjunction with medication administration. The pain management care plan interventions will be reviewed, revised, and updated by interdisciplinary team (IDT) members at resident's care conference to meet resident's needs. A review of the facility's undated policy titled "Pain Management" indicated the facility is FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 21 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE dedicated to a pain management program that is individualized according to the resident's needs and updated as needed. The pain management program consists of assessment, evaluation, documentation and reassessment. Health professionals will respond quickly to the residents' report of pain. The resident will be encouraged to assist in setting their own goals. A review of the facility's revised policy dated October 2010, titled "Care PlansComprehensive" indicated that assessments of residents are ongoing and care plan are revised as information about the resident and the resident's condition change. a.2. A review of the care plan dated December 6, 2017, indicated Resident 24 was at risk for fall related to unsteady gait, weakness, and history of fall. The goal indicated Resident 24 will have no incident of fall injury every shift for three months. The care plan intervention indicated to maintain a safe and hazard free environment (e.g. no wet floor, adequate lighting, no items that may cause tripping) and provide low bed with landing pads. A review of Resident 24's physician order dated December 6, 2017, indicated to provide the resident with a low bed with landing pads every shift. A review of the facility's Verification of Informed Consent to "Prolonged Use of Active Device" dated December 6, 2017, indicated the physician obtain consent for the use of a low bed with landing pads. A review of Resident 24's Medication Administration Record for the months of December 2017 and January 2018, indicated Landing pads were provided every shift from FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 22 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE December 7, 2017 to January 10, 2018. On January 10, 2018 at 10:49 a.m., during an observation, Resident 24 was lying in bed, no landing pads were observed on the floor. On January 10, 2018 at 3:05 p.m., during an observation, Resident 24 came out of the restroom using her walker. The landing pads were noted on the floor. Resident 24 stated that her walker was getting stuck on landing pads. Resident 24 also stated that the landing pads were placed for the first time the morning of January 10, 2018. Resident 24's family member (FM 1), who was present during the observation, stated that it was the first time she had seen the landing mats. On January 10, 2018 at 12:51 p.m., during an interview, Registered Nurse 1 (RN 1) stated that the landing pads indicated in Resident 24's care plan dated December 6, 2017, meant the intervention had been implemented. A review of the facility's revised policy dated October 2010, titled "Care PlansComprehensive" indicated the facility's care planning/interdisciplinary team, in coordination with the resident, his/her family or representative, develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes.

F658 SS=D Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i)

F658 03/14/2018 §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 23 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE plan, must(i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record reviews, the licensed nursing staff failed to follow professional standards of practice by failing to provide incentive spirometer (a device used to help keep the lungs healthy) for one of 25 sampled residents (Resident 24). This deficient practice had the potential to place the resident at risk for lungs infection, such as pneumonia. Findings: A review of the admission record indicated Resident 24 was admitted to the facility on December 6, 2018 with diagnoses that included muscle weakness and multiples fractures of ribs. A review of Resident 24's History and Physical report completed on December 10, 2017, indicated the resident had the capacity to understand and make decisions. A review of Resident 24's Minimum Data Set [MDS- a comprehensive assessment and screening tool] dated December 13, 2017, indicated the resident was cognitively intact. Resident 24 required extensive one-person assist with toilet use, personal hygiene, and bathing. A review of Resident 24's physician order dated December 8, 2017, indicated for the resident to use an incentive spirometer every hour for 10 hours while awake. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 24 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 24's Medication Administration Record (MAR) for the month of December 2017 and January 2018, indicated the incentive spirometer was provided to the resident every hour for 10 hours while she was awake from December 8, 2017 to January 10, 2018. On January 12, 2018 at 09:12 a.m., during an observation, Resident 24 was sitting in her chair. During a concurrent interview, Resident 24 stated that she never used the incentive spirometer and did not know what it was. Licensed Vocational Nurse 2 (LVN 2), who was present during the interview, stated that she had taken care of the resident in the past, but did not remember giving instructions to the resident regarding incentive spirometer. LVN 2 reviewed the physician order and stated that she had not given the resident the incentive spirometer on January 12, 2018. LVN 2 stated she should have given it to the resident. LVN 2 also stated that she would follow-up with her supervisor to check if the incentive spirometer equipment was available. On January 12, 2018 at 09:35 a.m., during an interview, the Director of Nursing (DON) stated that if Resident 24 was awake, alert, and oriented, the licensed nursing staff was to give instructions to the resident on how to use the incentive spirometer and remind the resident to use it at the frequency indicated by the MD order. The DON went to Resident 24's room, and the resident was observed telling the DON that she never used the incentive spirometer. On January 12, 2018 at 1:20 p.m., during a follow-up interview, the DON stated that the nursing staff should not have documented in Resident 24's MAR if the incentive spirometer was not provided to the resident. The DON also stated that licensed nursing staff did not follow FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 25 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the physician order.

F661 SS=B Discharge Summary CFR(s): 483.21(c)(2)(i)-(iv)

F661 03/14/2018 §483.21(c)(2) Discharge Summary When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following: (i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. (ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative. (iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-thecounter). (iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any postdischarge medical and non-medical services. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure a resident's discharge summary was completed and was provided to the resident prior to discharge from the facility for one of 25 sample residents (Resident 48). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 26 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This deficient practice had the potential to result in psychological stress and unsafe discharge. Findings: A review of the admission record indicated Resident 48 was admitted to the facility on October 12, 2017, with diagnoses that included right knee joint replacement and osteoarthritis (damage of the joint and the underlying bone that causes pain and stiffness, especially in the hip, knee, and thumb joints). A review of Resident 48's Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated October 16, 2017, indicated Resident 48's cognitive (relating to the process of acquiring knowledge and understanding) and decision making skills were intact. A review of Resident 48's Physician's Orders dated October 15, 2017, indicated to discharge resident home on October 16, 2017, with home health for physical therapy and occupational therapy for safety evaluation and treatment and registered nurse for medication reconciliation and treatment. A review of the Discharge Summary dated October 16, 2017, indicated the physician did not document the reason for transfer/discharge was necessary. A review of the Post Discharge Plan of Care dated October 16, 2017, indicated home health agency for nursing, physical therapy and occupational therapy were checked. However, the document did not indicate the name and phone number of the home health agency provided. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 27 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On January 12, 2018 at 4:24 p.m., during an interview, the Director of Nursing (DON) stated the discharge summary was not complete as the physician was supposed to indicate why the transfer was necessary. The DON stated the post discharge plan of care should have had the name and phone number of the home health agency. On January 12, 2018 at 4:26 p.m., during an interview, the Social Services Director (SSD) stated the name and phone number of the home health agency should have been documented on Post Discharge Plan of Care. A review of the facility's undated policy and procedure titled "Documentation of Transfers/Discharges" indicated all documentation concerning the transfer or discharge of a resident must be recorded in the resident's medical record. Should the resident be transferred or discharged for the following reasons, the basis for the transfer or discharge must be documented in the resident's clinical record by the resident's attending physician to include the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility or the transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility.

F677 SS=D ADL Care Provided for Dependent Residents CFR(s): 483.24(a)(2)

F677 03/14/2018 §483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 28 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide showers according to pre-determined schedule for one out of 25 sampled residents (Resident 24), who required assistance with activities of daily living (ADL). This deficient practice resulted in Resident 24 not receiving a shower for one month and had the potential to negatively impact Resident 24's self-esteem. Findings: A review of the admission record indicated Resident 24 was admitted to the facility on December 6, 2017, with diagnoses that included muscle weakness and difficulty in walking. A review of Resident 24's History and Physical report completed on December 10, 2017, indicated the resident had the capacity to understand and make decisions. A review of Resident 24's Minimum Data Set [MDS- a comprehensive assessment and screening tool] dated December 13, 2017, indicated the resident was cognitively intact. Resident 24 required extensive one-person assist with toilet use, personal hygiene, and bathing. A review of the care plan dated December 7, 2017 indicated Resident 24 required assistance with ADL due to decreased strength and balance. The care plan goal indicated the resident will have increased ADL independence daily until next review. The care plan FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 29 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE intervention indicated to assist with showers and toileting as needed. A review of the resident's shower schedule indicated Wednesdays and Saturdays as shower days for Resident 24. On January 10, 2018 at 3:08 p.m., during an observation, Resident 24 was sitting in her wheelchair, awake, alert, and responding appropriately to questions. During a concurrent interview, Resident 24 stated that she had not received a shower since her admission to the facility on December 6, 2017. Resident 24 stated that the nursing staff told her that she could not receive a shower because of the wound dressing on the left foot. When asked how it made her feel not to receive a shower for a month, Resident 24 stated "if you look at me that's not me, I am not able to keep up with my hair, I am sick and tired of sponge bath" On January 11, 2018 at 11:11 a.m., during an interview, the Director of Nursing (DON) stated that residents have pre-determined shower schedule. The DON stated that Resident 24's wound dressings on her lower extremities should not have prevented the nursing staff from providing Resident 24 with a shower. On January 12, 2018, during an interview, Certified Nursing Assistant 1 (CNA 1) stated that she had been assigned to Resident 24 few times in the past. CNA 1 stated that she had not assisted Resident 24 with a shower because Licensed Vocational Nurse 1 (LVN 1) told her that Resident 24 could not receive a shower due to the wound dressings on her lower extremities. CNA 1 also stated that it was possible to assist a resident with a shower even if the resident had wound dressing on the lower extremities. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 30 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the facility's undated policy and procedure titled "Shower/Tub Bath" indicated that the purpose of the procedure was to promote cleanliness, provide comfort to the resident and to observe the condition of the skin.

F684 SS=D Quality of Care CFR(s): 483.25

F684 03/14/2018 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the nursing staff failed to continuously evaluate pain and provide timely pain management for one of 25 sampled residents (Resident 24). This deficient practice resulted in Resident 24 experiencing pain and had the potential to result in a delay to promote healing of a pressure ulcer. Findings: A review of the admission record indicated Resident 24 was admitted to the facility on December 6, 2017, with diagnoses that included muscle weakness, multiples fractures of ribs, and non- pressure chronic ulcers of the lower extremities. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 31 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the care plan dated December 6, 2017 indicated Resident 24 was at risk for skin breakdown related to aging process and decreased mobility. The goal indicated Resident 24 will be free of skin breakdown through next review. The care plan interventions indicated to inspect skin daily during routine activities of daily living (ADL) care and report to charge nurse promptly for any new skin problems or concerns, perform skin assessment during weekly summary by charge nurses, and notify the physician/family of any changes in resident's condition. A review of Resident 24's skin progress report dated December 6, 2017, indicated the resident had a stage 1 pressure injury measuring 4 centimeters (cm) length by 4 cm width. The pressure injury resolved on December 10, 2017. A review of Resident 24's History and Physical report completed on December 10, 2017, indicated the resident had the capacity to understand and make decisions. A review of Resident 24's Minimum Data Set [MDS- a comprehensive assessment and screening tool] dated December 13, 2017, indicated the resident was cognitively intact. Resident 24 required extensive one-person assist with toilet use, personal hygiene, and bathing. The MDS also indicated Resident 24 had three stage 1 pressure ulcer (intact skin with non-blanchable redness of a localized area usually over a bony prominence). A review of the nurse's weekly summary notes dated December 13, 2017, indicated Resident 24 had a stage 1 pressure injury on the left and right heel. On January 10, 2018 at 3:10 p.m., during an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 32 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE observation, Resident 24 was awake, alert, and oriented to person, place, time, and situation. Resident 24's left foot had a wound dressing. On January 10, 2018 at 3:20 p.m., during an interview, Resident 24's family member (FM 1) stated that Resident 24 developed a wound on her left heel while resident at the facility. FM 1 stated that she did not know when the wound developed, but was notified by the resident's vascular surgeon during her last appointment. On January 12, 2018 at 12:35 p.m., during an interview, the Director of Nursing (DON) stated that Resident 24's stage 1 pressure injury dated December 13, 2017, was considered a new occurrence. On January 17, 2018 at 10:35 a.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated that she was not notified Resident 24 had a stage 1 pressure ulcer on December 13, 2017. LVN 1 also stated that it was the facility's procedure to complete a change of condition form, develop a care plan, and notify the physician when a new skin impairment was identified. LVN 1 stated that Resident 24 did not have any wound ulcer on her left heel until December 27, 2017, when the wound care consultant physician identified it during wound care rounds. On January 17, 2018 at 11:52 a.m., during a follow-up interview, the DON stated that she reviewed Resident 24's nursing notes and care plan, but could not provide documented evidence the licensed nursing staff monitored the resident's stage 1 pressure injury on the left heel after it was identified on December 13, 2017, developed a care plan addressing the left heel pressure injury, completed a change of condition, and notified the physician. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 33 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the facility's undated policy titled "Pressure Ulcers/Skin Breakdown- Clinical protocol" indicated the nursing staff and attending physician will assess and document an individual's significant risk factors for developing pressure sores; for example, immobility, recent weight loss, and a history of pressure ulcers. The nurse shall assess and document/ report the full assessment of pressure sore including location, stage, length, width, depth, and presence of exudates or necrotic tissue. The physician will help identify medical interventions related to wound management.

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 03/16/2018 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility failed to implement its policy and procedure for identifying resident who are at high risk for falls for one of 25 sampled residents (Resident 18). This deficient practice placed Resident 18 at risk for future additional falls and injury. Findings: According to the admission record, Resident 18 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 34 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE was admitted to the facility on November 15, 2017, with diagnoses that included difficulty walking and left intertrochanteric fracture (left hip fracture). A review of Resident 18's Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated December 13, 2017, indicated Resident 18's cognitive (relating to the process of acquiring knowledge and understanding) and decision making skills were severely impaired. Resident 18 was assessed as needing extensive assistance from 2 persons assist for moving in bed, transferring from bed to chair, and dressing. On January 11, 2018 at 9:00 a.m., Resident 18 was observed awake and lying in bed. A review of Resident 18's Fall Risk Assessment dated November 15, 2017, indicated Resident 18 score was 14. According to the assessment, a total score of 10 or above represent high risk for falls. A review of Resident 18's care plan dated November 15, 2017 for at risk for fall related to poor balance, unsteady gait, weakness, and history of fall (October 28, 2017), indicated the goal was for the resident not to have incident of falls/injury every shift for three months. The approaches included to maintain a safe and hazard free environment, assess degree of orientation, vision, and safety awareness of resident to determine safety needs and keep call light and frequently used items within reach. A review of Resident 18's "Interdisciplinary Post Fall Review" dated January 9, 2018, indicated Resident 18 had an unwitnessed fall on January 9, 2018 at 11:10 p.m. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 35 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 18's Physician's Orders dated January 10, 2018, indicated to transfer Resident 18 to the emergency room for further evaluation after an unwitnessed fall. On January 11, 2018 at 11:00 a.m., during an interview, the Director of Nursing (DON) stated Resident 18 was in falling star program (a program to reduce fall risks and fall rates in elderly residents of a long-term care nursing facility). The DON explained that residents who were in this program were identified by a star that was placed besides their names on the bedroom doors. On January 11, 2018 at 11:10 a.m., during a concurrent observation and interview, Registered Nurse Supervisor (RN 1) stated they place a star next to the resident's name when the resident was in the falling star program. RN 1 confirmed there was no star next to Resident 18's name. On January 11, 2018 at 12:01 p.m., during an interview, the DON stated she was not sure why there was no star beside Resident 18's name. A review the facility's undated policy and procedure titled "Fall Reduction Program" indicated the facility will identify, monitor and intervene as appropriate for all residents who have a history of falls or at risk to fall. The Policy and procedure indicated the identification of residents appropriate for the Fall Prevention Program will be accomplished through identifying high risk residents by placing a star besides their name on the bedroom door.

F697 SS=D Pain Management CFR(s): 483.25(k) FORM CMS-2567(02-99) Previous Versions Obsolete

F697 Event ID: 4OYJ11 03/14/2018 Facility ID: CA910000073 If continuation sheet 36 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.25(k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the nursing staff failed to continuously evaluate pain and provide timely pain management for one of 25 sampled residents (Resident 24). This deficient practice resulted in Resident 24 experiencing pain and had the potential to negatively affect the resident's psychosocial wellbeing and quality of life. Findings: A review of the admission record indicated Resident 24 was admitted to the facility on December 6, 2017 with diagnoses that included muscle weakness, multiples fractures of ribs, and chronic ulcers of the lower extremities. A review of Resident 24's History and Physical report completed on December 10, 2017, indicated the resident had the capacity to understand and make decisions. A review of Resident 24's Minimum Data Set [MDS- a comprehensive assessment and screening tool] dated December 13, 2017, indicated the resident was cognitively intact. Resident 24 required extensive one-person assist with toilet use, personal hygiene, and bathing. The MDS also indicated Resident 24 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 37 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE was occasionally experiencing pain rating nine out of 10 on a zero to 10 numeric pain scale, zero being no pain and 10 being the worst possible pain. A review of the care plan dated December 6, 2017, indicated Resident 24 had alteration in pain related to left rib fracture and cervical vertebrae fracture. The goal indicated the resident's pain will be decreased or controlled as evidenced by decreased request of pain medication. The care plan interventions indicated to assess and document characteristics of pain, provide comfort measured, administer medications as ordered, monitor for effectiveness, and notify the physician if ineffective. A review of Resident 24's physician order dated December 27, 2017, indicated to give the resident Norco (an opioid pain medication) 325 milligram (mg)- 5 mg, one tablet oral every four hours as needed for severe pain (8-10/10). On January 10, 2018 at 10:49 a.m., during an observation, Resident 24 was lying in bed and grimacing. During a concurrent interview, Resident 24 stated she was having foot pain. Resident 24 stated that she did not sleep well the night prior because of pain. Resident 24 stated that she requested pain medication on January 10, 2018 at 3 a.m., but was told it was too early to receive her pain medication. The nursing staff told her that she could not get the pain medication until 5 a.m. A review of the pain assessment flow sheet indicated Resident 24 received Norco 325 mg-5 mg on January 10, 2018 at 5 a.m. On January 10, 2018 at 3:10 p.m., during a follow-up interview, Resident 24 stated that she knew it was 3a.m. the morning of January 10, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 38 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2018, when she requested pain medication because she looked at the clock. Resident 24 stated that she could not sleep because of pain on her left leg, which at that time was 10 out of 10 on a zero to 10 pain rating scale. Resident 24 stated that the nursing staff told her that she could not give her pain medication till 5 a.m. (her next scheduled dose). Resident 24 stated that she "pleaded, begged" the nursing staff that she could not wait for 2 hours because she was in so much pain. Resident 24's family member (FM 1), who was present during the interview, stated that it was not the first time that the resident had requested pain medications and was asked to wait for her next scheduled dose. FM 1 stated Resident 24 called her earlier during the day and stated that she did not sleep because of pain, requested pain med, but the nurse told her it was not time for her pain medication. FM 1 also stated that resident 24's left foot has been hurting for about 2 weeks. On January 12, 2018 at 12:35 p.m., during an interview, the Director of Nursing (DON) stated that if Resident 24 was complaining of pain and it was not time for the next scheduled dose, the nursing staff should have notified the physician to inform him/her that the pain management was not effective. The DON stated that she reviewed Resident 24's initial pain evaluation and the evaluation did not address the resident's pain in her lower extremities. The DON also stated that Resident 24's care plan related to alteration in comfort did not address her lower extremities. The DON stated that Resident 24's care plan should have addressed the resident's lower extremities since the resident was receiving pain management for the lower extremities. The DON reviewed Resident 24's nurse's notes and stated that there were no indication the resident was experiencing pain on her left heel or that the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 39 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident had complained of pain at 3 a.m. on January 10, 2018. The DON stated there was no comprehensive assessment/evaluation regarding the resident's pain on her lower extremities. A review of the facility's undated policy titled "Pain Assessment and Management" indicated that it is the policy of the facility to assure that resident's pain is identified, monitored, and managed to provide relief in order to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Resident's pain status is assessed by a licensed nurse upon admission, every shift, complaint of new pain, before, during, and after care/treatment of therapy, and quarterly. The licensed nurse will administer pain medication per physician orders. The effectiveness of pain management interventions is evaluated and documented. A pain management plan of care is initiated, re-evaluated, or revised by the licensed nurse to include non-medication interventions that may be helpful either alone or in conjunction with medication administration. The pain management care plan interventions will be reviewed, revised, and updated by interdisciplinary team (IDT) members at resident's care conference to meet resident's needs. A review of the facility's undated policy titled "Pain Management" indicated the facility is dedicated to a pain management program that is individualized according to the resident's needs and updated as needed. The pain management program consists of assessment, evaluation, documentation and reassessment. Health professionals will respond quickly to the residents' report of pain. The resident will be encouraged to assist in setting their own goals.

F756 Drug Regimen Review, Report Irregular, Act FORM CMS-2567(02-99) Previous Versions Obsolete

F756 Event ID: 4OYJ11 03/14/2018 Facility ID: CA910000073 If continuation sheet 40 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) SS=D On CFR(s): 483.45(c)(1)(2)(4)(5) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.45(c) Drug Regimen Review. §483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. §483.45(c)(2) This review must include a review of the resident's medical chart. §483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. §483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 41 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on Interview and record review, the facility failed to act upon the consultant pharmacist's recommendation for the use of Nuedexta (a medication to treat involuntary episodes of crying and/or laughter) for one of 25 sampled residents (Resident 9). This deficient practice had the potential for adverse consequences. Findings: A review of the admission record indicated Resident 9 was re-admitted to the facility on May 11, 2011, with diagnoses that included hypertension (high blood pressure), hypothyroidism (a condition where the thyroid gland does not produce enough of a thyroid hormone called thyroxine), and atrial fibrillation (abnormal and irregular heart beat). A review of Minimum Data Set [MDS- a comprehensive assessment and screening tool] dated November 22, 2017, indicated Resident 9 had severe impairment of cognitive skills for daily decision making. A review of Resident 9's History and Physical report completed on February 26, 2017, indicated the resident did not have the capacity to understand and make decisions. A review of the pharmacist recommendation report dated November 19, 2017, indicated Resident 9 had a physician order for Nuedexa dated July 26, 2016. The consultant pharmacist recommended the following: 1. Consider obtaining serum potassium level, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 42 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE serum magnesium level, complete blood count levels, liver tests, and renal function tests if Nuedexta was to continue. 2. Re-evaluate Resident 9's electrocardiogram (test that measures the electrical activity of the heartbeat) if the risk factors for cardiac dysrhythmia (an abnormal heart beat) changed during the therapy. 3. Resident 9's thyroid-stimulating hormone (TSH- stimulates production of more hormones) level done on July 12, 2017, was high, consider ordering a current TSH level if clinically indicated. Under the physician response section, the physician disagreed with the pharmacist recommendation. The physician indicated that the risks outweighed the benefits, Resident 9 has schizophrenia, no gradual dose recommended at this time. A review of Resident 9's Medication Administration Record for the month of January 2018, indicated the resident received Nuedexta 20 milligrams (mg)-10 mg oral every 12 hours as indicated in the physician order. On January 11, 2018 at 12:02 p.m., during an interview, the Director of Nursing (DON) stated that the licensed nursing staff was responsible for ensuring that the pharmacist recommendations were acted upon. On January 17, 2018 at 12:30 p.m., during an interview, the Director of Nursing (DON) stated that the physician's medical justification did not address the pharmacist recommendation, dated November 19, 2017. The DON was unable to provide documented evidence that the consultant pharmacist recommendation for laboratory tests was followed through. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 43 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the facility's undated policy titled "Consultant Pharmacist Reports- Medication Regimen Review (Monthly Report)" indicated resident-specific irregularities and/or clinically significant risks resulting from or associated with medications are documented in the resident's (active record) and reported to the DON and/or prescriber as appropriate. Recommendations are acted upon and documented by the facility staff and or the prescriber. Physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing.

F761 SS=E Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 03/16/2018 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 44 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the safe storage of medications under proper temperature control for one of one Medication Room. This deficient practice had the potential to result in deterioration in the integrity of medication and potential for the residents to receive ineffective drug dosages. Findings: On January 10, 2018 at 9:17 a.m., during a Medication Storage Room inspection in the presence of Licensed Vocational Nurse 4 (LVN 4), a room thermometer was not noted. During a concurrent interview, LVN 4 was unable to state how the licensed nurses were ensuring that the medications were maintained under proper temperature. On January 17, 2018 at 2:17 p.m., during an interview, the Director of Nursing (DON) stated that the facility did not have a system of monitoring the Medication Storage Room to ensure safe storage of medications. A review of the facility's undated policy titled "Medication Storage in the MedRoom" indicated that medications and biologicals are stored safely, securely, and properly, following the manufacturer's recommendations or those of the supplier.

F805 Food in Form to Meet Individual Needs FORM CMS-2567(02-99) Previous Versions Obsolete

F805 Event ID: 4OYJ11 03/14/2018 Facility ID: CA910000073 If continuation sheet 45 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) SS=D CFR(s): 483.60(d)(3) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.60(d) Food and drink Each resident receives and the facility provides§483.60(d)(3) Food prepared in a form designed to meet individual needs. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure therapeutic diets were served as prescribed by the physician for two of 25 sampled residents (Resident 32 and 97). This deficient practice had the potential to cause the resident to choke on the food. Findings: a. On January 10, 2018 at 12:40 p.m., Resident 97 was observed sitting up in bed. Resident's private caregiver was assisting resident with her lunch. Resident's lunch tray had two slices of roast beef and two slices of garlic bread with crusts. The diet card indicated Resident 97 was on a lactose restricted mechanical soft diet. A review of the Physician's Order dated January 5, 2018, indicated an order for a lactose restricted mechanical soft diet for breakfast, lunch, and dinner. A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated January 12, 2018, indicated Resident 97 had severely impaired cognitive skills for daily decision making and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 46 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE required extensive assistance with one person assist for eating. A review of the care plan for at risk for alteration in nutritional status dated January 13, 2018, indicated the resident will improve oral meal intake of meals. The approaches included to provide diet as ordered. On January 10, 2018 at 12:40 p.m., during and interview, Dietary Service Supervisor (DSS) stated the cook made a mistake. The DSS also stated the meat was supposed to be chopped and the crust on the garlic bread should be removed. A review of the facility's Dysphagia Level 2 Mechanically Altered diet, indicated the diet consists of food that are moist, soft-textured, and easily form into a bolus. Meats are ground or are minced no larger than one-quarter-inch pieces, they are still moist with some cohesion. Meat are moistened ground or tender meat may be served with gravy or sauce. A review of the facility's Winter Menus Cooks Spreadsheet indicated for the mechanical soft diet; the beef roast should be grind and the garlic bread should be soft with no hard crusts. On January 16, 2018 at 4:45 p.m., during an interview, the Registered Dietitian 1 (RD 1) stated the meat should have been ground and regular soft bread should have been provided instead of the garlic bread according to the spreadsheet. b. On January 10, 2018 at 12:50 p.m., during an observation, Resident 32 was sitting in her bed with her lunch tray on the bedside table close by. The lunch tray had two slices of garlic bread with crusts. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 47 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE According to the admission record, Resident 32 was admitted to the facility on March 7, 2012, with diagnoses that included difficulty in walking and rheumatoid arthritis (a form of arthritis that causes pain, swelling, stiffness and loss of function in your joints that can affect any joint but is common in the wrist and finger). The diet card indicated Resident 32 is on a mechanical soft diet. A review of the Physician's Order dated April 24, 2015, indicated an order for a mechanical soft, small portions diet. A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated December 25, 2017, indicated Resident 32 had intact cognitive skills for daily decision making and required extensive assistance with one person assist for eating. A review of the care plan for at risk for alteration in nutritional status dated March 31, 2017 and last reviewed on December of 2017, indicated the resident's weight will remain stable with no change of plus or minus three pounds in one week or five pounds in one month. The approaches included to provide diet as ordered. On January 10, 2018 at 12:55 p.m., during and interview, Dietary Service Supervisor (DSS) stated the cook did not read the menu right. A review of the facility's Dysphagia Level 2 Mechanically Altered diet, indicated the diet consists of food that are moist, soft-textured, and easily form into a bolus. Meats are ground or are minced no larger than one-quarter-inch pieces, they are still moist with some cohesion. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 48 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Meat are moistened ground or tender meat may be served with gravy or sauce. A review of the facility's Winter Menus Cooks Spreadsheet indicated for the mechanical soft diet; the beef roast should be ground and the garlic bread should be soft with no hard crusts. On January 16, 2018 at 4:45 p.m., during an interview, the Registered Dietitian 1 (RD 1) stated the regular soft bread should have been provided instead of the garlic bread according to the spreadsheet.

F812 SS=L Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 03/14/2018 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 49 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on observation, interview, and record review, the facility failed to ensure food storage in the kitchen area were free of roaches to prevent foodborne illness for 44 of 44 residents residing in the facility. 1. Suppress cockroach population by maintaining an effective pest control service in the kitchen for sanitary food preparation. 2. Follow up with the Registered Dietitian monthly report findings of cracked flooring that had a potential to allow the entry of roaches into the kitchen food starage area. 3. Ensure food items were labeled and stored according to the facility's policy and procedure. 4. Ensure food temperatures were checked consistently prior to serving. For roaches to thrive, they need three components: water (moisture), food and temperature. The facility's wet floor provided the moisture that was needed to keep them thriving. The dirty food storage area and kitchen environment including cracks in the walls and floors provided both food and safe places to harbor and the warm kitchen conditions was the final conditions encouraging the roaches to thrive. The saliva, droppings and decomposing bodies of roaches contain proteins known to trigger allergies that can increase the severity of asthma symptoms. Roaches are also capable of mechanically transmitting disease causing organisms such as salmonella, and E. coli that can cause food poisoning. Nursing home residents risk serious complications from food poisoning as a result of their compromised health status. Symptoms of food borne illness included diarrhea, vomiting, headaches, fever, and confusion, loss of appetite, abdominal cramping and pain. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 50 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE When those conditions persist they can lead to dehydration and may require hospitalization and in some cases death. On January 10, 2018 at 5:30 p.m., an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) was called cross refer

F925, in the presence of the facility Administrator and Director of Nursing. An unacceptable plan of action was submitted to the survey team on January 10, 2018 at 7:30 p.m. An acceptable plan of action was submitted to the survey team on January 11, 2018, at 4:02 p.m., validated through observation, interview, and record review to verify facility compliance. The Immediate Jeopardy was abated on January 11, 2018 at 4:03 p.m. in the presence of the Administrator, when the facility implemented adequate measures to irradiate and prevent infestation of roaches, provide a sanitary kitchen and food storage area and was able to demonstrate knowledge of services necessary to ensure effective pest control management. Findings: A review of the facility's Resident Census and Condition of Residentsform CMS 672, indicated no residents are feed by tube feeding of 44 residents in the facility. On January 10, 2018 at 8:45 a.m., during the tour of the kitchen, the dry storage room was soiled with food debris and sticky material on the floor. There was an unlabeled half bag of carrots in the freezer, 2 bags of half used FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 51 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE sandwich bread, one half used bag of hot dog buns that was in the refrigerator. Spices that included nutmeg that was dated May 15, 2016, ground turmeric was dated June 14, 2016, ground all spices was dated March 25, 2016, ground thyme was dated June 10, 2016, whole bay leaf was dated June 3, 2016, and granulated garlic had a delivery date of October 17, 2017 and an open date of August 25, 2017 were observed on the kitchen shelves. On January 10, 2018 at 9:00 a.m., during an interview, the Dietary Service Supervisor (DSS) stated that the dietary staff should have labeled the packages when it was opened. DSS also stated he was responsible for checking the spices for expiration dates and rotating the spices. On January 10, 2018 at 9:40 a.m., upon further observation of the kitchen, two live roaches were observed crawling under the dishwasher area. One roach trap was found under the dishwasher area that was dated January 9, 2018. Inside the trap was one live roach and 15 different sized dead roaches. Cracked tiles were found under the dishwashing area with standing water pooled in the cracks, cracks in the walls and around the pipe by the dishwashing area allowed for pests and roaches to enter the kitchen. There were cracked tiles were found by the dry storage area and in the storage area allowing for pests and roaches to have shelter and to proliferate. There were gaps on the bottom of the door frame, and the base board was not attached to the wall by the freezer allowing for pests and roaches to enter the kitchen, to have shelter and to proliferate. On January 10, 2018 at 9:45 a.m., during an interview, Dietary Cook (DC) and Dietary Aide 1 (DA 1) stated they had never seen any FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 52 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE roaches in the kitchen. During a concurrent interview, Maintenance Supervisor (MS) stated traps were installed by pest control agent on January 9, 2018. Traps were for any types of animals. The MS also stated that he has been working at the facility for about three months and did not know when first trap was put in place. The MS further stated that there was no roaches or rodents problem and the pest control agent came on January 9, 2018. The MS observed one live roach in the trap and stated that this was the first time he had seen a live roach. A review of Pest Control Company 1 (PCC 1) contract dated August 15, 2017, indicated to cover the interior and exterior areas weekly for 52 services a year. The general pest services included the treatment of roaches. The maintenance program included weekly services to inspect and treat the exterior perimeter and trash enclosures, treat up to eight interior rooms per service, and inspect and treat the kitchen as necessary. A review of the PCC 1 Service Summary report indicated the following: 1. From January 3, 2017 through May 16, 2017, the pest control company was providing services on a weekly basis and no evidence of pest activity was found. The report indicated the targeted pest included ants, spiders, and roaches. 2. The PCC 1 Service Summary report indicated the targeted pest included ants, spiders, roaches, rats, and mice for May 30, 2017 and July 11, 2017 and no evidence of pest activity was found. 3. On June 6, 20, 27, 2017, PCC 1 Service Summary report indicated the targeted pest FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 53 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE included ants, spiders, and roaches for and no evidence of pest activity was found. 4. From August 30, 2017 through January 9, 2018, the PCC 1 was providing services on a weekly basis but no evidence of pest activity was found. The report indicated the targeted pest included roaches. On January 10, 2018 at 2:50 p.m., the survey team and the administrator attempted to call the PCC 1, to no avail. On January 11, 2018 at 8:45 a.m., the Administrator stated that it was concerning that the pest control agent and the Maintenance Supervisor (MS) did not report any pest activity after placing traps on a weekly basis. A review of PCC 2's Initial Inspection Observation report dated January 11, 2018, indicated the kitchen had evidence of German roach activity. The recommendation included to seal all gaps and cracks in the tiles along baseboards to reduce harborage spots, repair/replace any broken tiles, remove food and debris from floors, counters, drains and equipment, remove any standing water, keep drains clean and clear of debris. A review of the Registered Dietitian's Sanitation and Food Safety Checklist for the month of January, February, April, May, June, July, October, November and December of 2017, indicated "cracked in floor" and "needs repair." The report also indicated that all flooring was not in place (cracked, chipped, or missing). On January 11, 2018 at 11:30 a.m., during an interview, the Administrator stated that some of the findings on the Sanitation and Food Safety Checklist were not fixed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 54 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE No other roaches were observed during subsequent checks to the kitchen on January 11, 2018 from 3:00 p.m. to 3:30 p.m. All the walls and floor cracks had been repaired and sealed. A review of the Daily Food Temperatures Log indicated the following: 1. December 9, 2017: mechanical soft entrée, puree entrée, vegetable, puree vegetable for dinner did not have a temperature recorded and were documented as "cold plate." 2. December 23, 2017: puree vegetable for dinner did not have a temperature recorded. 3. December 25, 2017: puree eggs for breakfast did not have a temperature recorded. 4. December 26, 2017: puree toast for breakfast did not have a temperature recorded. 5. December 27, 2017: puree toast for breakfast, salad and puree starch for lunch did not have a temperature recorded. 6. January 6, 2018: there was a temperature that was record as "36 degrees Fahrenheit, however, there was no soup on the menu for dinner. 7. January 15, 2018: puree pancake/French toast for breakfast and mechanical soft entrée did not have a temperature recorded. 8. January 16, 2018: juice for breakfast, mechanical soft entrée, puree vegetable and dessert for dinner did not have a temperature recorded. On January 16, 2018 at 12:40 p.m., during an interview, RD 1 asked DA 2 if the temperature for the dessert was checked and DA 2 stated that he did not check the temperature. At 12:42 p.m., during a follow up interview on the same day, RD 2 stated the food temperatures should have been checked prior to serving. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 55 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On January 17, 2018 at 2:17 p.m., during an interview, the Administrator stated that the Quality Assessment and Assurance (QAA- a review for quality of care and quality of life) committee was not aware of roaches in the facility and should have been aware. He also stated the staff did not notice any activity in the facility. Administrator stated he did not know the pest control company was coming on a weekly basis prior to August. He also stated that it did not make sense for the pest control to come on a weekly basis when there was no pest activity found. The Administrator also stated the RD's recommendation to fix the cracks in the kitchen was not discussed in the QAA meeting. A review of the facility's undated policy and procedure titled, "Sanitation and Infection Control," indicated pest control is designed to maintain a sanitary environment which prevents contamination, transmission or spread of disease by insects or rodents. The kitchen will be kept clean, free from litter and rubbish, protected from rodents, roaches, flies and other insects. Store food properly to eliminate food sources for pests. A review of another facility's undated policy and procedure titled, "Storage of Food and Supplies," indicated food and supplies will be stored properly and in a safe manner. Store all food and supplies at least 18 inches from the ceiling for fire sprinkler clearance. All food will be dated with month, day and year. All food products will be used per the times specified in the "Dry Food Storage Guidelines." According to the facility's "Dry Goods Storage Guidelines," indicated opened ground spices can be stored on the shelf for one year.

F842 Resident Records - Identifiable Information FORM CMS-2567(02-99) Previous Versions Obsolete

F842 Event ID: 4OYJ11 03/14/2018 Facility ID: CA910000073 If continuation sheet 56 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) SS=E CFR(s): 483.20(f)(5), 483.70(i)(1)-(5) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is(i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 57 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for(i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the licensed nursing staff failed to maintain complete and accurate medical records in accordance with accepted professional standards for four of 25 sampled residents (Residents 24, 29, 43, and 149) by failing to: 1. Ensure the licensed nursing staff would not sign Resident 24's Medication Administration Record when the incentive spirometer (a device used to help keep the lungs healthy) was not provided as indicated in the physician FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 58 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE order. This deficient practice resulted in the medical record inaccurately representing care Resident 24 did not receive, and had the potential to place the resident at risk for lung infections, such as pneumonia. 2. Ensure there would be no discrepancy between the Controlled Drug Record (CDR) and the Pain Assessment Flow Sheet (PAFS) to assure the accurate disposition and/or administration of the medication as directed by the physician for Residents 24, 29, 43, and 149. This deficient practice had the potential not to readily identify drug diversion. Findings: a.1. A review of the admission record indicated Resident 24 was admitted to the facility on December 6, 2017 with diagnoses that included muscle weakness and multiples fractures of ribs. A review of Resident 24's History and Physical report completed on December 10, 2017, indicated the resident had the capacity to understand and make decisions. A review of Resident 24's Minimum Data Set [MDS- a comprehensive assessment and screening tool] dated December 13, 2017, indicated the resident was cognitively intact. Resident 24 required extensive one-person assist with toilet use, personal hygiene, and bathing. The MDS also indicated was occasionally experiencing pain nine out of 10 on a zero to 10 numeric pain scale, zero being no pain and 10 being the worst possible pain. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 59 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 24's physician order dated December 8, 2017, indicated the resident was to use an incentive spirometer every hour for 10 hours while awake. A review of Resident 24's Medication Administration Record (MAR) for the month of December 2017 and January 2018, indicated the incentive spirometer was provided to the resident every hour for 10 hours while she was awake from December 8, 2017 to January 10, 2018. On January 12, 2018 at 09:12 a.m., during an observation, Resident 24 was sitting in her chair. During a concurrent interview, Resident 24 stated that she never used the incentive spirometer and did not know what it was. Licensed Vocational Nurse 2 (LVN 2), who was present during the interview stated that she had taken care of the resident in the past, but did not remember giving instructions to the resident regarding incentive spirometer. On January 12, 2018 at 09:35 a.m., during an observation, Resident 24 told the Director of Nursing (DON) that she never used the incentive spirometer. On January 12, 2018 at 1:20 p.m., during an interview, the DON stated that the nursing staff should not have documented in Resident 24's MAR if the incentive spirometer was not provided to the resident. The DON also stated that licensed nursing staff did not follow the physician order. a.2. A review of Resident 24's physician order dated December 27, 2017, indicated to give the resident Norco (an opioid, a controlled pain medication) 325 milligram (mg)- 5 mg, give one tablet oral every four hours as needed for severe pain (8-10/10). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 60 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On January 10, 2018 at 7:14 p.m., during an inspection of Medication Cart # 1 in the presence of Licensed Vocational Nurse 3 (LVN 3), discrepancies were noted between Resident 24's CDR and PAFS as follows: 1. On December 28, 2017, the CDR indicated that Norco was administered at 1:40 a.m. However, the PAFS did not indicate that Norco was administered at that time. 2. On January 6, 2018, the CDR indicated that Norco was administered at 8 p.m. However, the PAFS did not indicate that Norco was administered at that time. 3. On January 7, 2018, the CDR indicated that Norco was administered at 3 p.m. However, the PAFS did not indicate that Norco was administered at that time. 4. On January 8, 2018, the CDR indicated that Norco was administered at 12 a.m. and 4 p.m. However, the PAFS did not indicate that Norco was administered at those times. On January 10, 2018, during an interview after completing the inspection of Medication Cart #1, LVN 3 stated that the nursing staff was to document in the CDR and PAFS after controlled medication administration. b. A review of the admission record indicated Resident 29 was admitted to the facility on December 15, 2017. A review of Resident 29's MDS (a comprehensive assessment and screening tool) dated December 22, 2017, indicated that Resident 29 had severe impairment in cognitive skills for daily decision making (related to thinking, reasoning, decision making and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 61 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE problem solving). The MDS also indicated that Resident 29 was occasionally experiencing pain, eight out of 10 on a zero to 10 numeric pain scale. A review of Resident 29's physician order dated December 15, 2017, indicated Norco (an opioid pain medication) 325 mg- 5 mg, give one tablet oral every four hours as needed for pain scale (5-10/10) not to exceed 3 grams in 24 hours. On January 10, 2018 at 7:14 p.m., during an inspection of Medication Cart # 1 in the presence of LVN 3, Resident 29's CDR indicated that Norco was administered on January 4, 2018 at 2:30 p.m., however, the PAFS did not indicate that Norco was administered on that date. On January 10, 2018, during an interview after completing the inspection of Medication Cart #1, LVN 3 stated that the nursing staff was to document in the CDR and PAFS after controlled medication administration. c. A review of the admission record indicated Resident 43 was admitted to the facility on December 21, 2017. A review of the MDS (a comprehensive assessment and screening tool) dated December 28, 2017, indicated that Resident 43 had intact cognition. The MDS also indicated that Resident 43 was occasionally experiencing pain, seven out of 10 on a zero to 10 numeric pain scale. A review of Resident 43's physician order dated December 21, 2017, indicated to give the resident following: 1. Norco 325 mg- 5 mg, give one tablet oral every four hours as needed for severe pain FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 62 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE scale (8-10/10) not to exceed 3 grams in 24 hours. 2. Tramadol Hydrochloride 50 mg tab, give one tab oral every six hours as needed for moderate pain (5-7/10). On January 10, 2018 at 7:14 p.m., during an inspection of Medication Cart # 1 in the presence of LVN 3, discrepancies were noted between Resident 43's CDR and PAFS as follows: 1. On January 1, 2018, the CDR indicated that Norco was administered at 12 p.m. However, the PAFS did not indicate that Norco was administered at that time. 2. On January 2, 2018, the CDR indicated that Norco was administered at 1 p.m. However, the PAFS did not indicate that Norco was administered at that time. 3. On January 3, 2018, the CDR indicated that Norco was administered at 1 p.m. However, the PAFS did not indicate that Norco was administered at that time. 4. On January 4, 2018, the CDR indicated that Tramadol was administered at 1 p.m. and Norco administered at 4 p.m. However, the PAFS did not indicate that Tramadol and Norco were administered at those times. 5. On January 5, 2018, the CDR indicated that Norco was administered at 5:30 p.m. However, the PAFS did not indicate that Norco was administered at that time. 6. On January 6, 2018, the CDR indicated that Norco was administered at 5:50 p.m. However, the PAFS did not indicate that Norco was administered at that time. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 63 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 7. On January 8, 2018, the CDR indicated that Norco was administered at 2 a.m., 2:30 p.m., at 7 p.m. However, the PAFS did not indicate that Norco was administered at those times. On January 10, 2018, during an interview after completing the inspection of Medication Cart #1, LVN 3 stated that the nursing staff was to document in the CDR and PAFS after controlled medication administration. d. According to the admission record, Resident 149 was admitted to the facility on January 6, 2017. A review of Resident 149's History and Physical report completed on January 8, 2018 indicated the resident had the capacity to understand and make decisions. A review of Resident 149's physician order indicated to give the resident the following: 1. Norco 325 mg- 5 mg, give one tablet oral every four hours as needed for pain scale (810/10), not to exceed 3 grams of APAP (acetaminophen, an analgesic drug) in 24 hours, dated January 6, 2018. 2. Tramadol Hydrochloride 50 mg tab, give one tab oral twice a day as needed for breakthrough pain, dated January 14, 2018. A review of Resident 149's CDR indicated that the resident received Tramadol on January 17, 2017 at 12 a.m. and 4 a.m. However the Pain Assessment Flow Sheet indicated Resident 149 received Norco at 12 a.m. and 4 a.m. On January 17, 2017 at 12:49 p.m., during an interview, the Director of Nursing (DON) stated that the licensed nursing staff documented the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 64 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Norco administration in error. The DON stated that Tramadol was administered at those times instead of Norco. A review of the facility's undated policy titled "Charting and Documentation" indicated that all services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. All observations, medications administered, services performed, etc., must be documented in the resident's clinical records. Documentation of procedures and treatment shall include care specific details and shall include at a minimum the date and time the procedure/treatment was provided, the name and title of the individual(s) who provided the care, the assessment data and/or any unusual findings obtained during the procedure/treatment, and how the resident tolerated the procedure/treatment. e. A review of the admission record indicated Resident 32 was admitted to the facility on March 7, 2012, with diagnoses that included difficulty in walking and rheumatoid arthritis (a form of arthritis that causes pain, swelling, stiffness and loss of function in your joints that can affect any joint but is common in the wrist and finger). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated December 25, 2017 indicated Resident 32 had intact cognitive skills for daily decision making and required extensive assistance with one person assist for eating. On January 10, 2018 at 11:00 a.m., Resident 32 was observed awake and lying in bed. During a concurrent interview, resident stated she reported to the nurse that she had pain in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 65 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE her right knee this morning. A review of Resident 32's Medication Administration Record for January 10, 2018, did not indicate pain medication was administered. A review of Resident 32's Pain Assessment Flowsheet, indicated there was no pre and post (before and after) pain assessment documented. A review of Resident 32's revised care plan goal dated December 2017, for at risk for alteration in comfort related to episodes of pain secondary to rheumatoid arthritis indicated for the resident to have resolution of pain within 30 minutes of intervention. The approaches included to assess level of pain, frequency, site and factors that trigger the pain and administer medication as ordered, and to document and notify physician of increasing and/or unrelieved pain. On January 10, 2018 at 1:00 p.m., during an interview, Licensed Vocational Nurse 6 (LVN 6) stated he administered the pain medication to Resident 32 and also performed the pre and post pain assessment. LVN 6 also stated that he would document at the end of the shift. LVN 6 stated that he did not write the information on a piece of paper and that he would remember the time when he administered the medication and the pre and post pain assessment was conducted. A review of the facility's undated policy and procedure titled, "Charting and Documentation," indicated all services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. All observations, medications administered, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 66 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE services performed, etc., must be documented in the resident's clinical records.

F880 SS=E Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 03/14/2018 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 67 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility dietary staff failed to observed infection control measures as directed on the facility's policy by not wash hands before and after touching the trash can twice during the kitchen tray line and changing gloves. This deficient practice had the potential to place all 44 facility residents at risk for food FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 68 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE borne illnesses. Findings: On January 16, 2018 from 11:50 a.m. to 12:36 p.m., during an observation of the tray line, the Dietary Cook (DC) was observed not washing his hands after touching the trash can with his bare hands that was next to the refrigerator by the stove and then handle the utensils in the drawer next to the steam table. The DC was observed not washing his hands after removing his gloves and putting on a new pair of gloves. On January 16, 2018 at 1:30 p.m., during an interview, the Registered Dietitian 2 (RD 2) confirmed that she did not observed DC washed his hands at any time during the tray line. DC should have washed his hands after touching the trash can and after changing his gloves. A review of the facility's undated policy and procedure titled, "Handwashing / Hand Hygiene," indicated employees must wash their hands for 10 to 15 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions that included after removing gloves. The us of gloves does not replace handwashing/hand hygiene. A review of another facility's policy and procedure dated 2018 and titled, "Food Handling," indicated all Food & Nutrition service personnel will wash their hands prior to handling all food. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 69 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F921 Safe/Functional/Sanitary/Comfortable Environ CFR(s): 483.90(i)

F921 03/16/2018

F925 03/14/2018 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.90(i) Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to maintain a sanitary laundry room free of a roach activity. These deficient practices had the potential to result in negative resident, staff, and public outcomes. A review of a pest control company Initial Inspection Observation report dated January 11, 2018, indicated in the laundry room, there was evidence of German roach activity found. The recommendation included to seal all gaps, around all pipes and wires leading into walls. This will help prevent travel through walls. On January 17, 2018 from 2:17 p.m. to 3:20 p.m., during an interview, the Administrator (ADM) stated that he was not notified of the pest control company providing services on a weekly basis prior August 2017. The ADM stated that the pest control report did not indicate any roaches activities, so he assumed the facility did not have any pest concerns. The ADM stated that the facility should have been aware of the roach infestation in the facility.

F925 SS=L Maintains Effective Pest Control Program CFR(s): 483.90(i)(4) §483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 70 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE rodents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to prevent the infestation of roaches in the emergency food storage area and kitchen for 44 of 44 residents in the facility when the facility failed to: 1. Suppress cockroach population by maintaining an effective pest control service in the emergency food storage area and in the kitchen. 2. Follow up with the Registered Dietitian the monthly report findings of cracked flooring in the kitchen that allowed for the entry of pests and roaches in the kitchen. 3. Maintain the kitchen in a sanitary manner. For roaches to thrive, they need three components: water (moisture), food and temperature. The facility's wet floor provided the moisture that was needed to keep them thriving. The dirty food storage area and kitchen environment including cracks in the walls and floors provided both food and safe places to harbor and the warm kitchen conditions was the final conditions encouraging the roaches to thrive. The saliva, droppings and decomposing bodies of roaches contain proteins known to trigger allergies that can increase the severity of asthma symptoms. Roaches are also capable of mechanically transmitting disease causing organisms such as Staphylococcus spp., Streptococcus spp., hepatitis virus, and coliform bacteria, salmonella, E. coli that can cause food poisoning. Nursing home residents were at risk for serious FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 71 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE complications of food borne illness as a result of their compromised health status. Symptoms of food borne illness included diarrhea, vomiting, headaches, fever, and confusion, loss of appetite, abdominal cramping and pain. When those conditions persist they can lead to dehydration and may require hospitalization and in some cases death. On January 10, 2018 at 5:30 p.m., an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) was called cross refer

F812, in the presence of the facility Administrator and Director of Nursing. An unacceptable plan of action was submitted to the survey team on January 10, 2018 at 7:30 p.m. An acceptable plan of action was submitted to the survey team on January 11, 2018, at 4:02 p.m., validated through observation, interview, and record review to verify facility compliance. The Immediate Jeopardy was abated on January 11, 2018 at 4:03 p.m. in the presence of the Administrator, when the facility implemented adequate measures to irradiate and prevent infestation of roaches, provide a sanitary emergency food area and kitchen and was able to demonstrate knowledge of services necessary to ensure effective pest control management. Findings: A review of the facility's Resident Census and Condition of Residents form CMS 672, indicated no residents are feed by tube feeding of 44 residents in the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 72 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On January 10, 2018 at 8:45 a.m., during the tour of the kitchen, the floor under the dishwashing area and the dry storage room was soiled with food debris. The dry storage room had sticky material on the floor. Spices that included nutmeg that was dated May 15, 2016, ground turmeric was dated June 14, 2016, ground all spices was dated March 25, 2016, ground thyme was dated June 10, 2016, whole bay leaf was dated June 3, 2016, and granulated garlic had a delivery date of October 17, 2017, and an open date of August 25, 2017, were observed on the kitchen shelves. On January 10, 2018 at 9:00 a.m., during an interview, the Dietary Service Supervisor (DSS) stated he was responsible for checking the spices for expiration dates and rotating the spices. On January 10, 2018 at 9:40 a.m., upon further observation of the kitchen, two live roaches were observed crawling under the dishwasher area. One pest trap was found under the dishwasher area that was dated January 9, 2018. Inside the trap was one live roach and 15 different sized dead roaches. Cracked tiles were found under the dishwashing area with standing water pooled in the cracks, cracks in the walls and around the pipe by the dishwashing area allowed for pests and roaches to enter the kitchen. There were cracked tiles were found by the dry storage area and in the storage area allowing for pests and roaches to have shelter and to proliferate. There were gaps on the bottom of the door frame, and the base board was not attached to the wall by the freezer allowing for pests and roaches to enter the kitchen. On January 10, 2018 at 9:45 a.m., during an interview, Dietary Cook (DC) and Dietary Aide 1 (DA 1) stated they had never seen any FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 73 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE roaches in the kitchen. During a interview, the Maintenance Supervisor (MS) stated traps were installed by pest control agent on January 9, 2018. The MS stated the traps were for any types of animals. The MS also stated he had been working at the facility for about three months but did not know when the first pest trap was put in place. The MS stated there was no roach or rodent problem and the pest control agent came on January 9, 2018. The MS observed one live roach in the roach trap and stated this was the first time he had seen a live roach. On January 10, 2018 at 10:15 a.m., during an observation of the Emergency Food Storage Room in the basement in the presence of the DSS, three black round pellets were found on the shelf. Outside of the Emergency Food Storage Room had a brown paper bag on the floor under the shelf. Upon opening the brown paper bag, one live roach crawled out of the bag and was crawling on the floor. The base board plaster was loose onto the side of the wall. During a concurrent interview, DSS stated he will clean the shelf in the Emergency Food Storage Room, threw the brown paper bag away, and let maintenance know about the live roach that was observed. A review of the pest control company 1 (PCC 1) contract dated August 15, 2017 indicated to cover the interior and exterior areas weekly for 52 services a year. The general pest services included the treatment of roaches. The maintenance program included weekly services to inspect and treat the exterior perimeter and trash enclosures, treat up to eight interior rooms per service, and inspect and treat the kitchen as necessary. On January 10, 2018 at 5:30 p.m., the Administrator stated he was not aware of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 74 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE infestation of roaches that was identified. On January 11, 2018 at 8:45 a.m., the Administrator stated that it was concerning that the pest control agent and the Maintenance Supervisor (MS) did not report any pest activity after placing traps on a weekly basis. A review of PCC 2's Initial Inspection Observation report dated January 11, 2018, indicated the following: 1. In the emergency food storage room, one German roach was found. 2. In the kitchen, evidence of German roach activity. The recommendation included to seal all gaps and cracks in the tiles along baseboards to reduce harborage spots, repair/replace any broken tiles, remove food and debris from floors, counters, drains and equipment, remove any standing water, keep drains clean and clear of debris. 3. In the laundry room, evidence of German roach activity found. The recommendation included to seal all gaps, around all pipes and wires leading into walls. This will help prevent travel through walls. A review of the Registered Dietitian's Sanitation and Food Safety Checklist for the month of January, February, April, May, June, July, October, November and December of 2017, indicated "cracked in floor" and "needs repair." The report also indicated that all flooring was not in place (cracked, chipped, or missing). On January 11, 2018 at 11:30 a.m., during an interview, the Administrator stated that some of the findings on the Sanitation and Food Safety Checklist were not fixed, such as the flooring. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 75 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE No other roaches were observed during subsequent checks to the kitchen, the emergency food storage room and in the laundry room on January 11, 2018 from 3:00 p.m. to 3:30 p.m. All the walls and floor cracks had been repaired and sealed. On January 17, 2018 at 2:17 p.m., during an interview, the Administrator stated that the Quality Assessment and Assurance (QAA-a review for quality of care and quality of life) committee was not aware of roaches in the facility and should have been aware. He also stated the staff did not notice any activity in the facility. Administrator stated he did not know the pest control company was coming on a weekly basis prior to August. He also stated that it did not make sense for the pest control to come on a weekly basis when there was no pest activity found. The Administrator also stated the RD's recommendation to fix the cracks in the kitchen was not discussed in the QAA meeting (to address the roach activity). A review of the facility's undated policy and procedure titled, "Sanitation and Infection Control," indicated pest control is designed to maintain a sanitary environment which prevents contamination, transmission or spread of disease by insects or rodents. The kitchen will be kept clean, free from litter and rubbish, protected from rodents, roaches, flies and other insects. Store food properly to eliminate food sources for pests. A review of the facility's undated policy and procedure titled, "Storage of Food and Supplies," indicated food and supplies will be stored properly and in a safe manner. Store all food and supplies at least 18 inches from the ceiling for fire sprinkler clearance. All food will be dated with month, day and year. All food products will be used per the times specified in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 76 of 77 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 01/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the "Dry Food Storage Guidelines." According to the facility's "Dry Goods Storage Guidelines," indicated opened ground spices can be stored on the shelf for one year. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4OYJ11 Facility ID: CA910000073 If continuation sheet 77 of 77